PiATE    I. 


TYPES  OF  BRAIN  CELLS  OCCURRING  IN  AMENTIA. 
(Drawn  as  seen  under  tV  inch  oil-immersion  lens.) 


,i    / 


Fig.  I. 


Fig.  2. 


Fig.  3. 


Fig.  4. 


s 


I. 


4.. 


/ 


14 


Fig.  5.  /    Fig.  6.  Fig.  /. 


4iw 


Fig.  S. 


A.  F.  TREDQOLD,  del.  1908. 


Fror,  'r'spifce.] 


DESCRIPTION   OF   PLATE   I. 

F"lG,  I. — Incompletely  developed  nerve  cells  (neuroblasts),  from  layer 
of  small  pyramids  of  frontal  cortex. 

Fig,  2. — Incompletely  developed  nerve  cell,  from  middle  pyramidal  layer 
of  motor  cortex. 

Fig.  3. — Neurog-lia  cell ;  from  a  case  of  sclerotic  amentia. 

Fig.  4  — Incompletely  developed  nerve  cells,  from  layer  of  middle  pyra- 
mids of  frontal  cortex. 

Fig.  5. — Atrophied  and  distorted  medium  pyramidal  nerve  cell;    from 
a  case  of  sclerotic  amentia. 

Fig.  6. — Medium  pyramidal  cell  from  frontal  cortex,  undergoing  subacute 
degeneration  ;    from  a  case  of  secondary  amentia. 

Fig.  7. — Medium  pyramidal  cell  from  frontal  cortex,  undergoing  chronic 
pigmentary  atrophy. 

F"iG.  8.— Pigmented  cell  of  hippocampus;   from  a  case  of  amentia  with 
epilepsy. 


^ 


p 


MENTAL  DEFICIENCY 

(AMENTIA) 


BY 

A.  F.  TREDGOLD 

L.R.C.P.    LOND.,    M.R.C.S.    Eng. 

Consulting  Physician  to  the  National  Association  for  the  Feeble-Minded,  and 

TO  the  Littleton   Home   for  Defective  Children  ;   Medical   Expert  to   the 

Ro¥AL  Commission  on  the  Feeble-Minded;  Formerly  Research  Scholar  in 

Insanity    and    Neuropathology  of   the   London  County   Council   and 

Assistant  IN  theClayburyI'athological  Laboratory  ;  Late  Resident 

Clinical  Assistant  in  the  Northumberland  County  Asylum,  etc 


/\\^AVijvl\''iy 


NEW    YORK 
WILLIAM    WOOD    &    COMPANY 

MDCCCCyill 


^ 


iJIOLOG^ 


MENTAL     DEFICIENCY 

(AMENTIA) 


I 


N 


TO 

ALL   THOSE    PERSONS   OF   SOUND    MIND 

WHO    ARE    INTERESTED    IN    THE    WELFARE 
OF   THEIR    LESS    FORTUNATE    FELLOW-CREATURES 


211v^82 


PREFACE 


During  the  past  few  years  the  subject  of  mental  deficiency  has 
evoked  a  large  amount  of  attention  from  many  prominent 
persons  interested  in  social  and  philanthropic  questions.  To 
members  of  the  medical  profession  in  particular  it  is  one  of  much 
importance,  on  account  of  their  responsible  duties  connected 
with  its  diagnosis,  with  the  treatment  and  training  of  these 
patients,  and  their  examination  and  certification  as  to  fitness 
for  special  classes  and  schools,  training-homes,  and  asylums. 
And  there  is  no  doubt  that  with  new  legislation,  which  cannot 
now  long  be  delayed,  these  duties  and  responsibilities  will  be 
considerably  increased. 

For  these  reasons  I  venture  to  hope  that  the  account  which  I 
have  attempted  to  give  in  these  pages  regarding  the  incidence, 
causation,  pathology,  mental  and  physical  characteristics,  social 
relationship,  diagnosis,  prognosis,  and  treatment  of  persons 
suffering  from  mental  deficiency,  will  be  found  to  justify  its 
pubHcation. 

To  a  great  extent  this  account  is  based  upon  observations  and 
researches  which  I  have  been  making  for  close  on  ten  years,  but 
I  have  also  made  full  use  of,  and  frequent  reference  to,  the 
writings  of  many  other  workers  in  this  field.  Valuable  help, 
permission  to  examine  cases  and  make  use  of  notes  and  illustra- 
tions, has  been  generously  accorded  me  from  many  quarters. 
In  particular  I  would  like  to  take  this  opportunity  of  gratefully 
acknowledging  my  indebtedness  to  the  members  of  the  Asylums 
Committee  of  the  London  County  Council ;  also  to  Dr.  Francis 
Warner,  London ;  Dr.  G.  A.  Sutherland,  London ;  Dr.  John 
Thomson,  Edinburgh  ;  Dr.  F.  W.  Mott,  F.R.S.,  Pathologist  to 


via 


Preface 


the  London  County  Asylums  and  Director  of  the  Pathological 
Laboratory  ;  Dr.  R.  R.  Alexander  and  Dr.  P.  Baily,  Hanwell 
Asylum  ;  Dr.  W.  J.  Seward,  Colney  Hatch  Asylum  ;  Dr.  J.  M. 
Moody,  Cane  Hill  Asylum  ;  Dr.  Robert  Jones,  Clay  bury  Asylum  ; 
Dr.  T.  W.  McDowall,  Morpeth  Asylum  ;  Dr.  F.  R.  P.  Taylor  and 
Dr.  C.  A.  Marsh,  formerly  of  Darenth  Asylum ;  Dr.  C.  Caldecott, 
Earlswood  Training  Institution  ;  and  Dr.  R.  Langdon  Down, 
Normansfield  Training  Institution. 

The  greater  portion  of  the  microscopical  work  was  carried  out 
in  the  Claybury  Pathological  Laboratory,  during  my  two  years' 
tenure  of  the  London  County  Council  Research  Scholarship  in 
Insanity  and  Neuropathology  ;  and  to  the  unequalled  advan- 
tages which  this  scholarship  afforded  for  clinical  and  patho- 
logical research  in  these  fields  of  medicine  I  desire  to  pay  a 
grateful  tribute. 

Finally,  I  wish  to  express  my  indebtedness  to  the  recently 
issued  voluminous  Reports  of  the  Royal  Commission  on  the  Care 
and  Control  of  the  Feeble-Minded.  Of  the  mass  of  information 
contained  in  these,  regarding  the  number  and  condition,  of  the 
mentally  deficient  population  of  this  country,  I  have  made-  full 
use.  It  is  necessary,  however,  to  add  a  word  of  explanation 
with  regard  to  statistics.  Under  the  term  "  mentally  defective  " 
the  Commissioners  include  sane  epileptics.  Since,  in  my  opinion, 
these  should  not  rightly  be  classed  as  aments,  I  have  considered 
it  advisable  to  make  independent  calculations  from  the  original 
returns — hence  the  slight  discrepancy  between  the  two  sets  of 
figures. 

A.  F.  TREDGOLD. 

6,  Dapdune  Crescent, 

Guildford,  Surrey, 

September,  igo8. 


TABLE    OF    CONTENTS 


PAGES 

PREFACE  -  -  -  -  -  -  -     vii,  viii 


•ER  ^^.^.-'''''''"'^ 

:N'ift<^UCTIOM 


I.  INXftODUCTION      ------  1-3 

Mental  deficiency.  Dementia.  Amentia.  Variations  in 
"  normal  "  mental  capacity,  Definition  of  the  "  normal  " 
mind.  Definitioa— ol-^mentia.  Relation  of  amentia  to 
normal,  to  dementia  and  to  insanity. 


II.   INCIDENCE  -  -  -  -  -  -  -         4-13 

Difficulty  of  enumeration.  Investigations  of  the  English  Royal 
Commission  of  1904.  The  number  of  aments  in  England  and 
Wales.  Incidence  of  the  three  degrees  of  amentia.  Incidence 
of  amentia  relative  to  insanity.  Location  of  aments  in 
England  and  Wales.     Incidence  with  regard  to  sex. 


III.  CAUSATION  -  -  -  -  -  -        14-50 

A. — Intrinsic  Factors  (Heredity)  : 

Diseases  of  the  nervous  system.  Alcoholism.  Tuberculosis. 
Syphilis.     Consanguinity.     Age  of  parents. 

B. — Extrinsic  Factors  (Environment)  : 

Acting  before  Birth. — Abnormal  conditions  of  mother  during 
gestation.  Mental.  Physical.  Illegitimacy.  Maternal 
impressions. 

Acting  during  Birth. — Abnormalities  of  labour.  Primogeni- 
ture.    Premature  birth. 

Acting  after  Birth. — Traumatic.  Toxic.  Epileptic  and  infan- 
tile convulsions.     Malnutrition. 

General  Considerations  : 

Modus  operandi  of  intrinsic  and  extrinsic  factors.  Illustrative 
family  history  charts.  Factors  of  causation  in  regard  to 
local  variations  of  incidence. 


Table  of  Contents 

CHAPTER  PAGES 

IV.  PATHOLOGY  -  -  -  -  -  -        51-70 

The  development  of  the  normal  brain. 
Pathology  of  Amentia  : 

The  essential  basis  of  amentia. 

Histology  : 

Cells  of  the  cortex  cerebri.  Fibres.  Neuroglia.  Vessels. 
Situation  of  the  cellular  changes.  The  histology  of 
secondary  amentia. 

Morbid  Anatomy  : 

Gross  developmental  anomalies  and  pathological  -  lesions. 
Hemiatrophy.  Microgyria.  Porencephaly.  Deficiency  of 
internal  structures.  Hydrocephalus.  Encephalitis  and 
meningo-encephalitis.     The  skull. 

V.  CLASSIFICATION  -  -  -  -  -71-77 

Division  of  amentia  into  forms,  degrees,  and  clinical  varieties. 

Forms : 

Primary.     Secondary.     Delayed  primary  or  developmental. 

Clinical  Varieties  : 

Of  primary  amentia  :  Simple,  Microcephalic,  Mongolian. 
Of   secondary   amentia :    Amentia  due    to    cerebral  disease, 
amentia  due  to  defective  cerebral  nutrition. 

Degrees : 

Feeble-mindedness  (Children  and  adults).  Imbecility.   Idiocy. 
"Moral  Imbecility."     Definitions. 

Table  of  Classification. 


VI.  PHYSICAL  CHARACTERISTICS  OF  AMENTIA  -         78-97 

Prevalence    of    physical    defects    in    amentia.      Stigmata    of 
degeneracy.     Table  of  anomalies. 

Anomalies  of  Anatomical  Development  : 

A.  Nervous  system.  B,  Special  sense  organs.  C.  Osseous. 
D.  Muscular  and  cutaneous.  E.  Circulatory  and  re- 
spiratory.    F.  Alimentary.    G.  Urinary  and  generative. 

Anomalies  of  Physiological  Function  : 

Of  special  organs  and  of  tissue  in  general.  Mortality.  Age 
periods  of  death.     Causes  of  deatli,  with  table. 


VII.  MENTAL  AND  NERVOUS  CHARACTERISTICS  -       98-122 

Sensory  : 
\/     Vision.  Hearing.  Taste.  Smell.  Cutaneous.  Muscle.  Organic. 


Table  of  Contents  xi 


MENTAL  AND  NERVOUS  CHARACTERISTICS  (continued)— 

Mental  : 

\_.  Attention.  Association  and  memory.  Imagination.  Ideation. 
Judgment  and  reasoning.  Temperament.  Emotion  and 
sentiment.     Volition. 

Motor  : 

Varieties  of  movements.  Anomalies  of  quantity  and  quality. 
Deficient.    Excessive.    Inco-ordinate.    Speech. 

VIII.  FEEBLE-MINDEDNESS     IN     CHILDREN      (MENTALLY 

DEFECTIVE  CHILDREN)  -  -  -  123-146 

Introductory  account,  with  early  inquiries  into  number  and 
condition.  Definition.  Special  schools  and  classes.  In- 
quiries of  Royal  Commission  of  1904.  Number.  Relative 
incidence  in  different  areas  of  the  United  Kingdom.  Rela- 
tive incidence  in  town  and  country.     Sex. 

Description  : 

Physical.  Nervous.  Mental.  Scholastic.  The  three  grades  of 
defect.  Mentally  defective  compared  with  normal  school- 
children.    Varieties  of  mentally  defective  children. 

Diagnosis  : 

Family  history.  Personal  history.  Present  state.  Differen- 
tial diagnosis  from  dull  and  backward  children,  delayed 
development,  dullness  due  to  ill-health,  epilepsy,  insanity, 
and  imbecility. 

IX.  FEEBLE-MINDEDNESS  IN  ADULTS  -  -  147-158 

Definition.     Number.     Sex. 

Description  : 

Physical  and  mental  characteristics.  The  "  stable  "  type. 
The  "  unstable  "  type.     Examples. 

y   X.  IMBECILITY  ------  159-164 

Definition.     Number.     Sex. 
Description  : 

Physical.     Mental  and  nervous.     Examples. 

W  XI.  IDIOCY  -  -  -  -  -  -  165-172 

Definition.     Number.     Sex. 

Description  : 

Partial  or  Incomplete  Idiocy. — Physical.    Mental  and  nervous. 

Apathetic  and  excitable  idiots.     Examples. 
Absolute  or  Complete  Idiocy. 

Diagnosis  of  Idiocy  and  Imbecility. 


/ 


xii  Table  of  Contents 

CHAPTER  "  PAGES 

XII.  CLINICAL  VARIETIES  OF  PRIMARY  AMENTIA  -      173-193 
Division  of  primary  aments  into  varieties. 

Microcephalics  : 

Introductory  account  and  number.  Causation.  Pathology. 
Relation  of  brain  weight  to  intellect.  Physical,  mental, 
and  nervous  condition.     Examples. 

Mongolians  : 

Introductory  account  and  number.  Causation.  Pathology. 
Description  of  physical,  mental,  and  nervous  characteristics. 

The  Complications  of  Primary  Amentia: 

Epilepsy.  Paralysis.  Hydrocephalus.  Porencephalus. 
Sclerosis.     Deaf-mutism. 

XIII.  CLINICAL  VARIETIES  OF  SECONDARY  AMENTIA    194-269 
Clinical  differences  between  primary  and  secondary  amentia. 
Section  I.  Amentia  due  to  Cerebral  Disease  : 

1.  Epileptic  and  eclampsic  amentia. 

2.  Vascular,    toxic,     and     inflammatory    amentia :    Poren- 

cephalic, sclerotic,  hydrocephalic. 

3.  Syphilitic  Amentia. 

4.  Infantile  Cerebral  Degeneration. 

Section  II.  Amentia  due  to  Defective  Cerebral  Nutri- 
tion. 

1.  Cretinism  :  Endemic,  sporadic. 

2.  Amentia  due  to  other  nutritional  defects. 

3.  Amentia  due  to  isolation  and  sense  deprivation. 

XIV.  IDIOTS  SAVANTS^  .  -  .  _  _      270-280 

Description,  with  illustrative  examples.   The  mechanical  Genius 
of  Earlswood  Asylum. 

XV.  THE  AMENT  AND  SOCIETY— PAUPER  AMENTS     281-292 
Location  of  the  mentally  deficient.     The  number  of  aments 
supported  at  the  public  expend.     Feeble-minded  in  re- 
ceipt of  parish  relief.      Idiots  and  imbeciles.      Vagrants. 
Aments  under  inadequate  care.     Propagation  by  aments. 

Y 
XVI.  MORAL  DEFICIENCY  AND  CRIMINAL  AMENTS      293-309 

Moral  Deficiency  : 

Latent  moral  defect.  Its  relation  to  amentia  and  to 
criminality.     Habitual  criminals  and  aments. 

Criminal  Aments  : 

Number.  Facile  type.  Impulsive  type.  Morally  defective 
or  habitual  criminal  type.     Illustrative  cases. 

Criminal  Responsibility  of  Aments  : 

Conditions  of  responsibility :  Defective  knowledge,  defective 
control,  delusions.     Civil  incapacity. 


Table  of  Contents  xiii 

CHAPTER  •  K  PAGES 

XVII.  INSANE  A^IENTS 310-323 

Sane  and  insane  aments.  Predisposition  to  insanity  in  aments. 
Borderland  of  amentia  and  insanity.  Relative  importance  of 
predisposing  and  exciting  factors.  Insanity  in  the  mild 
aments.  Mania.  Melancholia.  Stupor.  Alternating  insanity. 
Delusional  insanity.  Recurrences.  Dementia.  General 
paralysis.  Epileptic  insanity.  Insanity  in  imbeciles  and 
idiots.     Illustrative  cases. 

XVIII.  DIAGNOSIS  AND  PROGNOSIS     -  -  -  324-331 

Diagnosis  : 

In  infancy.     In  childhood.     In  later  years. 

Prognosis  : 

Of  the  forms,  varieties  and  degrees. 

I 
XIX.  TREATMENT  AND  TRAINING     -  -  -  332-356 

Medical  and  Surgical  Treatment. 

Education  : 

The  general  principles  of  education.  Home  training.  School 
training.  The  senses,  movement,  intelligence,  speech  and 
scholastic.     Industrial  training.     Moral  training. 

XX.  CpNCLUSION  -  -  -  -  -  357-362 

^he  necessity  for  training.  Supervision  and  after-care.  Pre- 
^  vention  of  propagation.    Sterilization.    Marriage.    Eradi- 
cation. 


APPENDIX  I.  A    TABLE    OF   NORMAL    DEVELOPMENTAL 

DATA  -  - 364,  365 

APPENDIX  II.     METHOD    OF    ESTIMATING    THE    TOTAL 

NUMBER  OF  AMENTS  IN  ENGLAND  AND  WALES     366-369 

APPENDIX  III.  THE  LAW  OF  ENGLAND  CONCERNING 
AMENTIA,  with  the  Recommendations  of  the  Royal 
Commission  (1904)      -----  370-376 


INDEX  - 377 


LIST   OF   TABLES 


TABLE  PAGE 

I.  Showing  the  Total  Number  of  Aments,  and  of  Idiots, 
Imbeciles,  and  Feeble-Minded,  per  1,000  Population, 
IN  Certain  Districts  of  the  United  Kingdom  -         6 

II.  Showing  the  Relative  Incidence  of  Amentia  in  Certain 

Areas  of  the  United  Kingdom  -  -  -         7 

III.  Approximate  Estimation  of  the  Total  Number  of  Aments, 

and  of  the  Respective  Degrees,  existing  in  England 
and  Wales  on  January  i,    1906  -  -  -         9 

IV.  Showing  the  Relative  Incidence  of  the  Degrees  of 

Amentia  in  Certain  Districts  of  the  United  Kingdom       10 
e  V.  The  Location  of  All  Aments  in  Eleven  Selected  Areas 

I  of  England  and  Wales  -  -  -  -       12 

VI.  Showing    the    Condition    of    150    Aments    with    their 

Brothers  and  Sisters    -  -  -  -  -       39 

VII.  Classification  of  Amentia  -  -  -  -  -77 

VIII.  Anatomical   and    Physiological   Anomalies   associated 

with  Amentia      -  -  -  -  -  -       82 

IX.  Relative  Mortality  of  Aments  and  Non-Aments  -       92 

X.  Showing  Age  Periods  of  1,000  Consecutive  Deaths  in 

Earlswood  Asylum         -  -  -  -  -       92 

XL  Showing  the  Percentage  of  Deaths  to  the  Number  of 
Patients  in  Residence  at  Earlswood* Asylum  over 
A  Period  of  Seventeen  Years  -  -  -  - 

XII.  Showing    the    Cause   of   Death    in    1,000    Consecutive 
^  Deaths  in  Earlswood  Asylum  -  -  -  - 

■    XIII.  Consonantal  Defects  in  Amentia  -  -  -     121 

■.     XIV.  Showing  the  Percentage  of  Mentally  Deficient  Chil- 
Wm  dren  to  the  Public  Elementary  School  Population 

^K  IN  Certain  Districts  of  the  United  Kingdom  -     126 

^H|  XV.  Showing  the  Relation  of  Epilepsy  to  Amentia  -     197 

^KXVI.  Showing  the  Location  of  Feeble-Minded   Persons  in 
^^P  Urban  and   Rural  Areas   respectively         -  -     286 

^^CVII.  The  Number  of  Aments  inadequately  cared  for  -     287 

Appendix  I.  A  Table  of  Normal  Developmental  Data  -     364 


93 

94 


LIST   OF    FAMILY    HISTORY    CHARTS 

CHART  •  PAGE 

L  Showing  Good  Heredity  contaminated    by  Slight  Alco- 
holic Heredity  and  Town  Life  -  -  -  -     41 
II.  Showing  Good   Heredity  contaminated   by  Morbid   He- 
redity           --            -            -            -            -            -41 

III.  Showing   Good    Heredity   contaminated   by   Insane   He- 

redity -  -  -  -  -  -  -42 

IV,  Showing  the  Effect  of  Insane  +  Phthisical  Heredity      -     42 
V.  Showing  the   Effect   of  Alcoholic   and    Insane   Inheri- 
tance +  Phthisical  Inheritance  -  -  -     43 

VI,  Showing  the  Effect  of  Double  Morbid  Heredity  -  43 

VII.  Showing  the  Effect  of  Double  Morbid  Heredity  -  44 

VIII.  Showing   the   Effect    of    a  Double  Insane   Inheritance 

+  Syphilis  -  -  -  -  -  -  -  44 

IX.  Showing  the  Effect  of  Consanguinity  with  a  Tendency 

TO  Vascular  Lesions  of  the  Brain        -  -  -  45 


XVI 


LIST   OF   ILLUSTRATIONS 


PLATE         FIGS.  PAGE 

1.       1-8.  Types  of  Brain  Cells  occurring  in  Amentia 

Frontispiece 
II.  9.  Diagrammatic   Sections   of   Frontal  Cortex  in 

Amentia,  Dementia,  and  the  Normal  Brain   -  6^, 

10.  Schema  for  taking  Cranial  Measurements         -  85 

TO   FACE  PAGE 

III.   1 1 -1 6.  Mentally  Defective  School-Children     -             -  128 

IV.  17-18.  Primary  Amentia,  Feeble-Mindedness,  Mentally 
Stable  Type  (Males)      -             -             -             -  150 

V.  19-20.  Primary  Amentia,  Feeble-Mindedness,  Mentally 
Unstable  Type  (Females)          -             -             -  i54 

VI.  21-22.  Primary    Amentia,    Imbecility,    Mentally    Un- 
stable Type  (Males)      -             -             -             -  160 

Primary  Amentia,  Imbecility  (Females)    -             -  162 
-26.  Primary  Amentia,  Imbecility  (Males)       -             -  164 
Primary  Amentia,  Imbecility         -             -             -  166 
Primary  Amentia,  Idiocy  with  Sclerosis               -  166 
Primary  Amentia,  Idiocy,  Excitable  Type            -  168 
Primary  Amentia,  Microcephalic  Variety             -  176 
Primary  Amentia,  Mongolian  Variety     -             -  184 
Primary  Amentia,  Mongolian  Variety,  Children  186 
Primary  Amentia,  Mongolian  Variety,  Children  188 
Secondary  Amentia  due  to  Epilepsy      -             -  200 
Secondary  Amentia  due  to  Cerebral  Lesion    -  200 
Secondary   Amentia   with    Paralysis   and    Con- 
vulsions due  to  Infantile  Lesion     -             -  214 
42.  Secondary    Amentia    with    Paraplegia    due    to 

Vascular  Lesion  at  Birth        -             -             -  214 
XVII.         43.  Secondary  Amentia  with  Epilepsy  due  to  En- 
cephalitis IN  Infancy  -            -            -            -  218 

44.  Secondary    Amentia    due    to    Encephalitis    in 

Infancy    -  -  -  -  -  -218 

XVIII.         45.  Secondary  Amentia  due  to  Sclerosis  (so-called 

"  Hypertrophy  of  the  Brain  ")           -             -  232 
xvii 


VII. 

23-24. 

VIII. 

25-26. 

IX. 

27. 

28. 

X. 

29-30. 

XI. 

31-32. 

XII. 

33-34. 

XIII. 

35-36. 

XIV. 

37-38. 

XV. 

39. 

40. 

XVI. 

41. 

2''  • ' " '  •    ■  Men-tal  Deficiency 

normal  Mind.     Corresponding  differences  are  present  amongst 
barbarians   and  savages,    and   probably  have   always   existed. 
What,  then,  is  to  be  considered  the  standard,  and  how  and  where       ^ 
are  we  to  draw  a  line  which  shall  divide  the  normal  from  the — 
abnormal,   the  least   intellectually  gifted  members   of  normal 
mankind  from  the  population  which  is  mentally  deficient  ? 

It  is  not  easy  to  do  this,  but  I  think  that  our  best  definition 
of  the  ''  nnrrnal  "  vn,\r\c\  must  bf  ^  r^Pgrpp  nf  intellectual  capacity 
suffi£i£nt-ta^nable  it.§. posaessBX-to  p.erfQr4n  his  duties  as  a  member 
of  society  in  that  position  of  life  to  which  he  is  born. 

"fortunately  for  human  progress,  the  mental  capacity  of  many 

persons  suffices  for  this,  and  more  ;  but  where  there  is  any  falling 

short  of  this  irreducible  minimum,  then  I  think  we  must  say  that 

the  bounds  of  normal  variation  have  been  overstepped,  and  that 

a  condition  of  incomplete  development,  or  amentia,  is  present. 

•JJ^We  may  thus  define  amentia  as  a  stat^jipiiinifal  defect  frnwc^irth^^^^ 

^       or  fronL-mi-£arlv  ase^  due  to  incomplete  cerebral  development,  in 

!JS>^^>consequence  of  i^)hich  the  per^nnaffp,r,tpJ.  /!■<:  umHc  t'^  p^vfnrm  hi^ 

'^^^^^    duties  as  a  member  of  Rcieietyjin  the  position  of  life  to  wMch  he  i?.„ 

born. 

It  is  not,  however,  to  be  assumed  that  amentia  is  merely  a 
subtraction  in  varying  degree  from  the  normal.  Although  the 
contrary  might  be  thought,  nevertheless  the  two  conditions  do 
not  merge  into  one  another,  and  between  the  lowest  normal  and 
the  highest  ament  a  great  and  impassable  gulf  is  fixed.  Whilst 
the  former  is  heavy,  stolid,  and  uniformly  dull-witted,  he  has 
yet  sufficient  common  sense  to  look  after  his  interests  and  hold 
his  own  in  that  environment  in  which  Nature  has  placed  him. 
The  mildest  ament,  on  the  other  hand,  may  show  no  apparent 
dullness  ;  he  may  even  be  bright  and  vivacious,  and  in  some  of 
his  abilities  immeasurably  superior  to  the  clodhopper.  But  the 
other  faculties  of  his  mind  are  not  present  in  like  proportion. 
Instead  of  harmonious  working  there  is  discord,  and  in  the  pos- 
session of  that  essential  to  independent  existence — common 
sense — he  is  lacking,  and  the  want  can  never  be  supplied. 

The  difference  has  been  well  described  by  Sir  J.  Batty  Tuke,* 
who  says  :  "  Where  in  theory  the  morbid  and  the  healthy  types 
might  be  supposed  to  approach  each  other,  we  find  in  practice         i 

^Article  "  Insanity,"  "  Encyclopaedia  Britannica." 


Introduction  '; 

that  no  such  debatable  ground  exists.  The  uniformity  of  dull- 
ness in  the  former  stands  in  marked  opposition  to  the  irregularity 
of  mental  conformation  in  the  latter." 

The  fact  is  that  amentia  is  not  merely  a  mental  subtraction, 
but  a  distinct  j)athological_^condition  which  is  produced  by 
disease.  The  cerebral  tissues  concerned  in  Mind  do  not  suffer 
from  a  uniform  arrest  of  their  development  at  a  point  which  is 
inadequate  for  the  needs  of  everyday  life,  but  their  whole  growth 
and  development  is  irregular.  Even  the  function  of  the  parts 
laid  down  is  often  imperfect  and  perverted,  the  total  result  being 
not  only  mental  defect,  but  mental  discord. 

The  two  other  chief  forms  of  mental  disease  are  dementia  ald_^     .. 
insanity.     The  former  of  these  has  already  been  referred  to,  ^^^^ 
and  is  the  resi^t^of  neuronic  degeneration  j_whilst  "  insanity  "        T^ 
is  the  clinical  manifestation  of  a  disturbance  or  perversion  of 
neuronic  function,  which  may  or  may  not  terminate  in  deg^nera^   '^ 
tion,  and  which,  as  we  shall  subsequently  see,  is  by  no  means 
incompatible^vilhjieuroniajieficiency  or  amentia. 

The  su  b]  ect^ofamentia,  therefore,  whilst  presenting  many 
interesting  problems  to  the  physician,  the.  pathologist,  and  the 
psychologist,  has  also  a  much  wider  interest  and  importance. 
Since  in  Man  the  predominant  feature  is  Mind,  and  since  it  is 
by  the  development  of  this  faculty  that  human  progress  has 
taken,  and  must  take,  place,  it  is  clear  that  the  question  of 
its  disease,  and  particularly  of  its  defect,  is  one  of  supreme 
importance  to  the  statesman,  the  sociologist,  and  the  philo- 
sopher. 


1—2 


CHAPTER    II 

INCIDENCE 

The  enumeration  of  the  mentally  deficient  population  of  any 
country  is  an  extremely  difficult  matter,  and  there  can  be  no 
doubt  that  most  official  inquiries,  particularly  those  by  means 
of  the  ordinary  census,  fall  very  far  short  of  the  truth.  The 
reasons  for  this  are  numerous,  the  chief  being  the  inability  or 
unwillingness  of  parents  to  recognize  mental  abnormality,  their 
total  incapacity  to  distinguish  between  its  various  forms,  and 
their  not  unnatural  reluctance  to  proclaim  its  presence  on  a 
census  paper.  The  milder  forms  of  defect,  which  are  at 
once  the  most  important  from  a  sociological  aspect,  and  the 
most  frequent,  cannot  possibly  be  detected  by  such  means. 
For  these  reasons  I  am  of  opinion  that  the  official  returns  of 
any  country  respecting  the  number  of  its  aments  are  so  unreli- 
able and  incomplete  that  no  useful  purpose  would  be  served  by 
quoting  them. 

Investigations  of  the  Royal  Commission  of  1904. 

In  this  country,  however,  an  enumeration  has  recently  been 
made  on  quite  another  basis.  In  the  year  1904  a  Royal  Com- 
mission was  appointed  to  consider  the  existing  methods  of 
dealing  with  these  persons,  and  the  Commissioners  decided  that, 
before  any  practical  scheme  of  administration  could  be  formu- 
lated, it  was  imperative  that  they  should  obtain  approximately 
accurate  information  as  to  the  number  and  condition  of  the  class. 
With  this  object,  a  series  of  personal  investigations  were  insti- 
tuted on  a  considerable  scale,  and  this  is  the  first  systematic 
attempt  which  has  been  made  to  obtain  reliable  data.     It  is 

4 


Incidence     '  5 

« 

not  too  much  to  say  that  these  inquiries  have  added  enormously 
to  our  knowledge  regarding  the  condition,  manner  of  living,  and 
environment  of  the  aments  of  this  country,  besides  making  it 
possible  to  calculate  their  total  number  with  a  degree  of  accuracy 
hitherto  unattainable. 

The  method  adopted  by  the  Royal  Commission  consisted  of  a 
series  of  elaborate  and  searching  inquiries  by  a  number  of  medical 
men,  to  each  of  whom  a  selected  area  was  assigned.  The  in- 
vestigator was  instructed  to  visit  personally  all  public  elementary 
schools,  poor-law  institutions,  charitable  establishments,  training- 
homes,  reformatories,  common  lodging-houses,  prisons,  idiot 
asylums,  hospitals,  and,  indeed,  any  establishment  likely  to 
harbour  the  mentally  abnormal.  Further,  he  was  to  see  persons 
in  receipt  of  out-door  relief,  to  apply  to  the  clergy,  medical  prac- 
titioners, the  police,  charity  organization  societies,  and  similar 
agencies,  and,  in  short,  to  make  use  of  any  and  every  channel 
which  might  help  him  to  make  the  enumeration  complete. 

It  was  not  found  practicable  to  investigate  the  whole  of  the 
country  in  this  way,  but,  in  order  that  conclusions  applicable  to 
the  entire  country  might  be  drawn,  a  selection  of  certain  typical 
areas  was  made.  Altogether,  there  were  examined  nine  areas  in 
England,  two  in  Wales,  one  in  Scotland,  and  four  in  Ireland, 
having  an  aggregate  population  of  3,873,151. 

I  shall  again  allude  to  many  facts  revealed  by  this  inquiry  in 
subsequent  chapters  ;  but  in  this  place  some  statistics  regarding 
the  ascertained  number  of  aments  may  be  quoted. 

The  total  number  of  aments  varies  in  the  different  areas 
examined,  and  although  to  a  slight  extent  this  may  be  due  to 
different  personal  equations,  in  many  cases  the  difference  is  so 
great  that  it  can  only  be  regarded  as  the  result  of  a  real  difference 
of  incidence.     This  is  shown  in  the  following  table  : 


Mental  Deficiency 


TABLE  I.* 

Showing  the  Total  Number  of  Aments,  and  of  Idiots,  Imbeciles, 
AND  Feeble-minded  respectively,  per  i,ooo  Population,  in 
Certain  Districts  of  the  United  Kingdom,  according  to  the 
Investigations  of  the  Royal  Commission,   1904. 


Feeble-minded. 

Idiots. 

Imbe- 
ciles. 

Total 
Aments. 

Adults. 

Children. 

Manchester    .  . 

0-05 

0-32 

I-20 

2-IO 

3-74 

Birmingham  .  . 

0-09 

0-27 

170 

I -60 

3-76 

Urban 

Hull    .. 

0'02 

0-20 

0-55 

0-58 

1-35 

Glasgow 

0-07 

0-23 

0-32 

I-OO 

1-68 

Dublin 

0-19 

0-57 

I-20 

2-IO 

414 

.Belfast 

0-13 

0-63 

0-70 

0-97 

2-45 

r  Stoke-on-Trent 
Industrial . .  '  Durham 
ICork    .. 

0'2I 

0-45 

2-IO 

I-IO 

3-96      I 

0-02 

0-34 

0-56 

0-56 

1-48 

0-07 

0-32 

0'i6 

0-54 

110 

Mixed        rNottingham 

0-30 

0-66 

■ 

1-50 

I-20 

3-81      ' 

Industrial    |      shire 

! 

and          1  Carmarthen- 
Agricultural  V     shire 

0-S9 

0-65 

0-51 

I-20 

3-05 

i 

1 
1 

'Somersetshire 

o-i8 

i-oo 

2-IO 

I-IO 

4-54 

Wiltshire 

0'35 

0-69 

2-20 

0-90 

4-25 

Agricultural- 

Lincolnshire  . . 

0-44 

0-98 

1-40 

1-70 

4-68^ 

Carnarvonshire 

0-24 

0-58 

2-IO 

0-94 

3-96 

.Galway 

0-13 

I-oo 

I-OO 

2-20 

4-49 

It  will  be  seen  from  this  Table  that,  whilst  the  mean*  average 
incidence  of  total  amentia  in  the  sixteen  areas  is  3*28  per  1,000 
population,  the  variation  ranges  from  a  minimum  of  I'l,  in  the 
case  of  Cork,  to  a  maximum  of  4 "68  in  the  case  of  Lincolnshire. 
The  following  table  shows  the  areas  grouped  according  to  the 
prevalence  of  amentia  : 


*  The  figures  in  this  table  slightly  underestimate  the  true  incidence 
for  t'  eason  that  they  do  not  include  a  small  proportion  of  cases  certified 
under  t  e  Lunacy  Act. 


Incidence 


TABLE  II. 

Showing  the  Incidence  of  Relative  Amentia  in  Certain  Areas 
OF  THE  United  Kingdom. 


Low  Incidence 

{under  ^  per  i,ooo 

Population). 

Mean  Average  Incidence 

(3  to  4  per  1,000 

Population) . 

High  Incidence 

(over  4.  per  1,000 

Population). 

Hull 
Glasgow- 
Belfast 
Durham 
Cork 

Manchester 

Birmingham 

Stoke-on-Trent 

Nottinghamshire 

Carmarthenshire 

Carnarvonshire 

Dublin 

Somersetshire 
Wiltshire 
Lincolnshire 
Galway 

It  is  thus  seen  that  the  incidence  of  amentia  in  this  country 
is  far  from  being  uniform  ;  that,  in  fact,  great  differences  exist 
between  areas  in  which  there  is  little  difference  in  physical, 
social,  and  industrial  features.  By  means  of  the  annual  reports 
of  the  Lunacy  Commissioners  1  have  ascertained  that  the  same 
applies,  to  the  incidence  of  insanity,  and  that,  on  the  whole, 
there  is  a  tolerably  close  correspondence  between  the  relative 
extent  of  the  two  conditions  (amentia  and  insanity).  The 
cause  of  this  differing  prevalence  of  mental  disease  is  not  clear, 
and  its  investigation  would  probably  necessitate  very  minute 
inquiries  into  the  social,  industrial,  and  hereditary  condition  of 
the  people  over  a  long  period.  Since,  however,  it  relates  rather 
to  mental  disease  in  general  than  to  amentia  in  particular,  it  is 
beyond  the  scope  of  this  work  to  do  more  than  allude  to  it. 


The  Number  of  Aments  in  England  and  Wales. 

If  the  incidence  of  amentia  were  tolerably  uniform  throughout 
the  country,  it  would  be  a  very  simple  matter  to  calculate  the 
total  number  of  affected  persons  from  the  figures  revealed  by 
this  inquiry  ;  but,  as  we  have  seen,  the  incidence  is  very  far 
from  being  uniform.  It  would  also  be  quite  easy  could  it  be 
shown  that  the  proportion  of  low  to  high  prevalent  areas  in  those 
examined  were  relatively  the  same  as  obtains  in  the  whole 
country — if,  in  fact,  we  could  be  certain  that  we  were,  ^^aling 
with  a  fair  sample — but  there  is  no  a  priori  evidence  'hat  this 


8  •  Mental  Deficiency- 

is  so.  Consequently  the  estimation  is  a  somewhat  complicated 
one.  I  believe,  however,  that  by  using  the  incidence  of  insanity 
as  a  standard  we  may  arrive  at  a  result  which  is  approximately 
correct.  All  insane  persons  are  not,  of  course,  certified,  but  the 
returns  of  the  Lunacy  Commissioners  regarding  the  number  of 
the  certified  pauper  insane  may  be  accepted  as  a  sufficiently 
accurate  indication  of  the  relative  prevalence  of  insanity  in  the 
various  union  districts  of  England  and  Wales.  The  incidence 
of  amentia,  as  already  remarked,  is,  on  the  whole,  directly  pro- 
portionate to  the  incidence  of  insanity.  Now,  if  we  calculate 
the  proportion  per  i,ooo  population  of  the  certified  pauper 
insane  in  the  eleven  areas  of  England  and  Wales  investigated 
by  the  Royal  Commission  of  1904,  it  works  out  at  3*15  ;  but  if 
we  calculate  the  proportion  per  1,000  of  the  certified  pauper 
insane  throughout  the  country  (using  in  each  case  the  returns 
of  the  Lunacy  Commission*  and  the  population  according  to 
the  1901  census!),  it  works  out  at  342.  So  that  the  mean 
average  incidence  of  insanity,  and  consequently  of  amentia,  in 
these  areas  is  less  than  the  mean  average  for  the  entire  country, 
and  this  can  only  be  due  to  the  fact  that  the  eleven  areas  examined 
contain  a  greater  relative  proportion  of  districts  of  low  inci- 
dence. 

The  actual  number  of  aments  in  the  country  is  therefore 
expressed  by  the  equation  : 

Aments  :  certified  insane  :  :  aments  :  certified  insane 


in  areas  examined  in  England  and  Wales 

From  which  it  follows  that  the  total  number  of  aments  in  Eng- 
land and  Wales  on  January  i,  1906,  was  approximately  138,529 
persons,  equivalent  to  (with  an  estimated  population  on  that 
date  of  34,349,435,  according  to  the  Registrar-General)  4*03 
persons  per  1,000,  or  i  in  every  248.  { 

*  Total  pauper  certified  insane  in  England  and  Wales  on  January  i, 
1906,  according  to  the  Sixtieth  Report  of  Lunacy  Commissioners  = 
111,256.  Total  pauper  insane  in  the  areas  investigated,  as  obtained  from 
Table  I.,  Appendix  B,  of  same  report=  7,328. 

f  Population  of  England  and  Wales,  according  to  1901  census  = 
32,525,716.  Population  of  the  eleven  areas  examined,  according  to  1901 
census  =  2,32i,567. 

\   For  further  particulars  and  corrections,  see  "  Appendix  II. 


Incidence  9 

The  Number  of  Persons  suffering  from  Each  of  the  Three  Degrees 
of  Amentia  in  England  and  Wales. 

This  may  be  calculated  in  a  similar  manner  to  the  foregoing, 
and  the  results  arrived  at  are  shown  in  the  following  table  : 

TABLE  III. 

Approximate  Estimation  of  the  Total  Number  of  Aments,  and  of 
THE  'Respective  Degrees,  existing  in  England  and  Wales  on 
January  i,  1906. 

{Estimated  Total  Population  according  to  Registrar-General,  34,349,435.) 

Idiots       ..  ..  ..     8,654    persons,  or  0-25  per  1,000  population. 

Imbeciles  . .  . .   25,096  ,,  0-73 

Feeble-minded!  ^^'^''^*^       54,ii4*         »  i'57 

i<eeDiemmaea|^.j^^^^^^    50,665  „  1-47 

Total         ..     138,529  ,,  4*03 

(or  I  person  in  every  248) 

The  Relative  Incidence  of  the  Three  Degrees  of  Amentia. 

It  is  seen  from  Table  III.  that  idiots  are  decidedly  the  least 
numerous  of  the  three  degrees  of  amentia  ;  that  imbeciles  occur 
next  in  frequency,  being  nearly  three  times  as  plentiful  ;  whilst 
the  number  of  the  feeble-minded  is  more  than  three  times  as 
great  as  the  idiots  and  imbeciles  combined.  In  other  words, 
taking  the  country  as  a  whole,  there  are  in  every  100  aments  : 

Idiots.  Imbeciles.  Feeble-minded. 


Adults.  Children. 

6  18  39  37 

Or,   in  every  10,000  population  there  are   (taking  the  nearest 
whole  numbers)  : 

Idiots.  Imbeciles.  Feeble-minded.  Insane. 


Adults.  Children. 

2  7  15  14  36 

*  It  seems  probable  that  the  excess  of  adult  over  juvenile  feeble- 
minded is  due  to  the  inclusion  in  the  former  group  of  4,450  patients  in 
asylums.  The  majority  of  these  belong  to  the  mildest  type  of  mental 
defect,  and  are  detained  on  account  of  insanity  or  epilepsy.  If  seen  during 
the  school  period,  they  would  probably  be  looked  upon  as  doubtful,  and 
given  the  benefit  accordingly.  Their  condition  becomes  obvious  when 
competition  with  the  outside  world  has  to  be  faced. 


lO 


Mental   Deficiency 


There  are,  however,  certain  variations  in  the  relative  incidence 
of  these  degrees  of  amentia  which  seem  to  be  referable  to  the 
environment,  and  to  these  brief  allusion  must  be  made.  It  is 
found  that  the  severer  degrees  of  defect  (idiots  and  imbeciles) 
are  both  relatively  and  absolutely  much  more  numerous  in 
agricultural  than  in  urban  and  industrial  areas,  whilst  in  the 
case  of  the  juvenile  feeble-minded  (mentally  defective  children) 
the  results  are  reversed,  these  being  both  relatively  and  absolutely 
more  numerous  in  urban  than  in  agricultural  areas.  The  actual 
figures  will  be  seen  by  reference  to  Tables  1.  and  IV. 


TABLE  IV. 

Showing  the  Relative  Incidence  of  the  Degrees  of  Amentia  in 
Certain  Districts  of  the  United  Kingdom.  Calculated  from 
the  Returns  of  the  Royal  Commission,    1904. 


In 

Every   100  Aments 

there 

are — 

' 

Imbeciles. 

Feeble-minded. 

Idiots. 

Adults. 

Children. 

'Manchester    . , 

1-5 

8-6 

31-0 

S7'0 

, 

Birmingham 

2-5 

7-2 

45'0 

44-0 

Urban  .  .       . . , 

Hull 

i-S 

7-8 

44-0 

46-0 

Glasgow 

4-3 

13-7 

19-4 

62-6 

Dublin 

4-6 

14-0 

30-0 

51-3 

.Belfast 

5-3 

25-9 

29-0 

39-5 

r  Stoke-on-Trent 

5-3 

11-4 

53-0 

30-0 

Industrial     . .  J  Durham 

1-5 

23-0 

37-0 

38-0 

tCork 

6-7 

29-0 

15-0 

49-0 

Mixed  Indus- 1  „  ...     ,         ,• 

8-1 

17-0 

41-0 

32-0    1 

14-0 

22-0 

i8-o 

44-0 

'Somersetshire 

4'0 

23-0 

47-0 

25-0 

Wiltshire 

8-3 

15-0 

52-0 

23-0    ! 

Agricultural    - 

Lincolnshire  . . 

9-5 

2I-0 

3I-0 

37-0    1 

Carnarvonshire 

6-0 

I4-0 

55-0 

24-0    1 

Galway 

2-9 

22-8 

23-7 

50-5     1 

Incidence  1 1 

Inasmuch  as  the  inquiries  from  which  these  statistics  are  com- 
piled excluded  all  'persons  certified  under  the  Lunacy  Act,  there 
is  a  slight  fallacy  in  these  figures.  In  order  to  ascertain  the 
extent  of  this,  I  made  a  special  investigation  as  to  the  total 
number  of  aments  (certified  and  uncertified)  in  a  few  of  the 
areas  examined.  The  results  show  that  the  proportion  excluded 
does  not  appreciably  alter  the  relative  incidence  as  shown  in 
Table  IV.  The  cause  of  this  difference  of  relative  incidence  will 
be  discussed  in  a  subsequent  chapter. 


Incidence  of  Amentia  relative  to  Insanity. 

It  has  been  stated  that  the  incidence  of  amentia  is  directly 
proportionate  to  that  of  insanity,  and  on  the  whole  this  is  true  ; 
for  it  is  found  that  where  insanity  is  rife  amentia  is  also  prevalent, 
and,  conversely,  where  there  is  little  insanity  there  is  little 
amentia.  The  inquiries  of  the  Royal  Commission  show,  how- 
ever, that  the  relative  incidence  of  these  two  forms  of  mental 
disease  is  subject  to  slight  variations  according  to  the  environ- 
ment, and,  generally  speaking,  amentia  would  appear  to  be 
relatively  more  prevalent  in  rural,  and  insanity  in  urban,  districts. 

The  aments  are  a  slightly  more  numerous  class  than  the 
insane,  for  a  calculation  of  the  total  number  of  the  latter  (un- 
certified as  well  as  certified)  shows  that  the  approximate  number 
of  this  class  in  England  and  Wales  on  January  i,  1906,  was 
125,827,  corresponding  to  3-66  per  1,000  population,  or  to 
I  person  in  every  273. 

The  approximate  total  number  of  persons  suffering  from  all 
forms  of  pronounced  mental  disease  (amentia,  insanity,  and 
dementia)  in  England  and  Wales  is,  therefore,  264,  356,  equivalent 
to  7*69  per  1,000,  or  i  person  in  every  130. 


Location. 

In  order  to  give  a  general  idea  as  to  the  location  of  these 
aments  I  append  the  following  table  (V.),  which  shows  the 
situation  of  the  8,079  persons  revealed  by  the  inquiries  of  the 


12 


Mental  Deficiency 


Royal  Commission,  together  with  those  not  so  included  on  account 
of  being  certified  under  the  Lunacy  Act  : 


TABLE  V. 

Location  of  all  Aments  in  Eleven  Selected  Areas  of  England 
AND  Wales.  Mainly  based  upon  the  Inquiries  of  the  Royal 
Commission,   ,1904. 


Feeble-minded. 

Imbe- 

Totals. 

ciles. 

Idiots. 

i 

1 

Juvenile. 

Adult. 

Persons. 

Percent. 

(a)  In  institutions  : 

Poor  Law 

83 

1,387 

152 

47^ 

Charitable* 

34 

115 

Idiot  asylums   . . 

3 

22 

60 

15 

Lunatic  asylums 

366 

276 

92  ■ 

2,866 

32-5 

Prisons  . . 



197 

Inebriate  homes 

— 

17 

— 

— - 

(b)  In  receipt  of  out- 

door relief 

10 

358 

237 

103 

708 

8-0 

(c)   Not  receiving  re- 

lief : 

I .  Friends  able  to 

make  partial  or 

full  permanent 

provision 

50 

234 

138 

72 

494 

5-6 

2.  Friends  unable 

to    make    per- 

manent provi- 

sion   , . 

217 

926 

434 

147 

1,724 

19-5 

(d)  In  public  elemen- 

tary  or    special 

schools 

2,936 

II 

74 

— 

3,02 1 

34-2 

Totals 

3.333 

3.633 

1,371 

476 

8,813 

*  Charitable  institutions  are  composed  as  follows  : 

Institutions  for  the  blind,  deaf,  crippled,  epileptic,  and   defective, 

21  persons. 
Training  and  rescue  homes,  penitentiaries,  etc.,  128  persons. 


Incidence 


13 


Incidence  with  Regard  to  Sex. 

I         The  sex  of  the  12,120  aments  discovered  in  sixteen  areas  of  the 
I      United  Kingdom  is  as  follows  : 


Idiots. 

Imbe- 
ciles. 

Feeble-minded. 
Children.       Adults. 

Totals. 

Males 

Females 

303 
282 

959 
848 

3,244 
2.193 

2,179 
2,112 

6.685 
5,435 

It  is  thus  seen  that,  considered  either  in  regard  to  each  degree 
or  collectively, "  there  is  a  slight  preponderance  of  the  male  sex, 
the  relative  proportion  of  males  to  females  being  practically  as 
6  to  5.  It  is  probable  that  of  all  aments  born  a  considerably 
greater  proportion  than  this  are  of  the  male  sex  ;  but  that  the 
number  of  these  is  subsequently  diminished  by  a  relatively 
higher  infantile  mortality. 

That  a  greater  number  of  aments  are  to-day  resident  in  institu- 
tions than  was  the  case  a  generation  back  is,  I  think,  incontestable, 
and  the  exigencies  of  modern  life  must  undoubtedly  lead  to  an 
increase  of  this  number  in  years  to  come  ;  but  as  to  whether  the 
condition  is  or  is  not  more  prevalent  than  formerly,  or  as  to 
the  relative  incidence  in  different  countries,  we  have  no  data 
upon  which  to  form  an  opinion.  It  is  quite  clear,  however, 
from  the  statistics  here  given,  that  even  on  account  of  its  present 
prevalence  the  condition  is  one  deserving  of  the  gravest  con- 
sideration. 


CHAPTER  III 


CAUSATION 


Amentia  has  been  defined  as  mental  deficiency  due  to  imperfect 
or  arrested  cerebral  development,  and  in  the  investigation  of 
its  causes  we  have  to  inquire  into  all  the  influences  concerned 
in  embryonic  development,  as  well  as  those  affecting  the  growth 
of  the  brain  after  birth.  In  other  words,  we  must  ascertain  as 
completely  as  possible  the  family  and  the  early  personal  history 
of  these  afflicted  persons.  Now,  such  an  inquiry  is  by  no  means 
easy  ;  it  requires  not  only  a  considerable  amount  of  special  know- 
ledge in  order  rightly  to  interpret  the  accounts  furnished  by 
unscientific,  and  often  ignorant,  persons,  but  it  also  demands  much 
patience  and  tact.  The  not  unnatural  reluctance  evinced  by  the 
majority  of  persons  to  admit  the  presence  of  mental  unsound- 
ness in  the  family  often  leads  to  the  deliberate  withholding  of 
information,  whilst  a  strongly  prejudiced  view  of  the  importance 
of  some  one  particular  factor  may  cause  all  others  to  be  ignored, 
and  so  greatly  mislead  the  investigator.  I  do  not  think  there 
is  any  disease  in  which,  in  the  minds  of  parents  and  relatives, 
the  post  hoc  ergo  propter  hoc  opinion  figures  more  largely. 

Nevertheless,  a  very  large  number  of  cases  have  now  been 
examined,  and  although  the  opinions  of  inquirers  differ  slightly 
as  to  their  relative  importance,  there  is  a  very  general  agreement 
as  to  the  main  influences  which  are  responsible  for  the  imperfect 
condition  of  the  brain  cells. 

It  would  be  too  large  a  task  to  refer  to  all  the  work  which 
has  been  done  in  this  direction,  even  in  this  country  alone ;  and 
as  I  have  myself  devoted  much  time  to  the  subject,  and  have 
investigated  the  antecedents  of  a  large  number  of  these  patients, 
I  propose  to  give  my  own  results,  alluding  where  necessary  to 
•  14 


Causation  15 

the  points  upon  which  they  differ  from  those  of  other  inquirers. 
My  reason  for  doing  this  is  that  the  question  of  causation  not 
only  involves  the  ascertainment  of  facts,  but  the  careful  analysis 
and  consideration  of  such  facts  in  conjunction  with  the  clinical 
features  of  the  patients,  and  I  feel  more  competent  to  do  this 
with  data  personally  collected  than  with  those  obtained  by  other 
persons.  My  investigations*  embrace  patients  seen  in  the 
asylums  of  the  London  County  Council,  the  special  institutions 
at  Darenth  and  Earlswood,  the  Littleton  Home  for  Defective 
Children,  and  my  own  private  practice,  and  they  include  every 
grade  and  variety  of  amentia.  This  point  is  important,  because 
the  type  of  case  varies  much  in  different  institutions,  and 
statistics,  however  numerous,  which  are  confined  to  any  one 
institution  are  apt,  on  that  account,  to  be  misleading. 

In  dealing  with  this  subject,  it  has  been  the  usual  custom  for 
writers  to  divide  the  cases  into  two  groups — "  congenital  ' ' 
and  "  acquired."  Such  a  division  is  open  to  the  objection  that 
what  wotrld  be  termed  a  congenital  condition  may  really  be  due 
to  a  factor. of  the  environment,  and  acquired  in  utero.  The  real 
question  is  the  relative  f)^ts  played  by  heredity  and  environ- 
ment. Accordingly,  I  have  thought  it  better  to  use  the  terms 
intrinsic  and  extrinsic.  Intrinsic  factors  are  hereditary  influ- 
ences which  modify  the  germinal  plasm  before  conception  takes 
place,  and  the  form  of  amentia  so  produced  may  be  termed 
primary.  Extrinsic  factors  are  those  conditions  of  the  environ- 
ment which  affect  the  development  of  the  brain  (and  body) 
either  whilst  yet  within  or  without  the  uterus,  and  in  this  case 
the  amentia  may  be  termed  secondary.  The  various  etiological 
factors  will,  therefore,  be  discussed  in  the  following  order  : 

(^  )*T5trinsic — Heredity. 

1 .  Disease  of  the  Nervous  System. 

2.  Alcoholism. 

3.  Tuberculosis. 

4.  Syphilis. 

5.  Consanguinity. 

6.  Age  of  Parents. 


/ 


*  An  analysis  of  150  of  these  was  given  in  my  article  on  "  Amentia  "  in 
Mott's  "  Archives  of  Neurology,"  vol.  i.  Nearly  another  hundred  have 
since  beei>  investigated,  with  practically  identical  results. 


i 


Mental  Deficiency 


(B)  Extrinsic — Environment. 


(a)  Before  Birth 


{b)  During  Birth 


(c)  After  Birth 


/ 


1.  Abnormal  Conditions  of  the  Mother  during  Preg- 

nancy— (i)  Mental,  (2)   Physical. 

2.  Injuries  to  the  Foetus. 

1 .  Abnormalities  of  Labour.  • 

2.  Primogeniture.  ," 

3.  Premature  Birth. 

1.  Traumatic, 

2.  Toxic. 

3.  Epileptic  and  Infantile  Convulsions. 

4.  Malnutrition. 


{A)  Causes  Inherent  in  the  Germinal  Plasm — Heredity. 

I.  Disease  of  the  Nervous  System. 

It  is  agreed  by  all  who  have  studied  this  question,  that  the 

lost  frequent  cause  of  amentia  is  some  ancestral  pathological 

ondition — morbid  heredity.     It  is  also  agreed  that  the  com- 

lonest  form  of  morbid  heredity  is  disease  of  the  nervous  system. 

n  a  small  proportion  of  cases  the  antecedent  nervous  disease 

onsists  of  cerebral  haemorrhages,  paralysis,  or  various  neuroses  ; 

)ut  in  the  great  majority  it  is  insanity,  dementia,  or  epilepsy.     My 

>wn  inquiries  showed  that  over  80  per  cent,  of  persons  suffering 

rom  the  severer  grades  of  amentia  were  the  descendants  of  a  pro- 

lounced  neuropathic  stock.     In  64  per^cent.  the  heredity  was  In 

.^e  form  of  insanity  or  epilepsy  ;  whilst  in  18  per  cent,  it  consisted 

)f  a  marked  family  tendency  to  paralysis,  cerebral  haemorrhages, 

3r  various  neuroses  and  psychoses.     Somewhat  similar  results, 

showing  the  great  prevalence  of  this  factor,  have  been  obtained 

by  other  investigators.  .  For  instance,  in  England  it  was  found. 

by  Beach  and  Shuttleworth*  that  insanity,  epilepsy,  and  allied 

aeuroses  were  well  marked  in  the  ancestors  of  42  per  cent,  of 

he  patients  they  examined  ;  but  Dr.  Caldicott  considers  that  70  to 

5  per  cent,  have  neuropathic  antecedents.     In  America  a  Com- 

hiission   appointed   by   the   Legislature   of   Connecticut   found 

neuropathic  heredity  to  be  the  undoubted  cause  in  43  per  cent. 

In  Germany  Kochf  came  to  the  conclusion  that  it  accounted  |or 

*  Beach  and  Shuttleworth,  Clifford  AUbutt's  "  System  of  Medicine," 
Ivol.  vii, 

t  J.  L.  A.  Koch,  "  Zur  Statistik  der  Geisterkrankheiten  in  AViirtemberg, 
unci  der  Geisterkr.  iiberhaupt,"  Stuttgart,  1878. 


Causation  17 

60  per  cent,  of  cases.  In^  Switzerland  (Canton  of  Berne)  the 
census  of  1893  showed  that  heredity  was  present  in  55  per  cent, 
of  idiots  ;  whilst  in  Norway  Ludwig  Dahl  found  it  to  occur  in 
50  per  cent,  of  cases. 

It  is  seen  that  my  own  results  are  considerably  higher  than  those 
obtained  by  most  other  observers,  and  it  is  necessary  to  explain 
the  discrepancy.  I  believe  it  to  be  entirely  a  question  of  the 
method  adopted.  Most  statistics  relating  to  this  subject  have 
been  compiled  from  case-books  or  official  returns,  and  although 
by  this  means  an  immense  amount  of  material  is  available,  the 
details  must  necessarily  be  lacking  in  the  accuracy  and  com- 
pleteness obtainable  by  a  personal  inquiry.  Again  and  again 
have  I  discovered,  by  a  little  questioning,  a  well-marked  history 
of  insanity,  of  which  no  record  whatever  existed  in  the  official 
case-book  ;  and  it  is  my  opinion  that,  although  statistics  based 
upon  these  may  be  of  value  as  showing  the  relative  importance  of 
the  different  factors,  they  are  practically  valueless  as  an  indica- 
tion of  the  precise  extent  to  which  these  factors  occur. 

It  was  the  recognition  of  the  incomplete  and  unsatisfactory 
details  in  the  case-books,  including  some  of  those  which  have 
formed  the  basis  for  previous  generalizations  on  this  matter, 
which  decided  me  to  conduct  an  independent  and  personal 
inquiry  into  the  causation  of  amentia.  Unfortunately,  the 
taking  of  a  reliable  family  history  involves  much  time  and 
trouble.  It  is  essential  to  gain  the  confidence  of  the  relatives, 
and  it  is  often  necessary  to  interview  several  members  of  the 
family  before  all 'the  requisite  details  can  be  elicited.  More- 
over, family  histories  can  rarely  be  considered  satisfactory  unless 
they  include  particulars  of  three  generations.  For  these  reasons 
a  personal  inquiry  of  this  kind  can  only  be  based  upon  a  com- 
paratively small  number  of  cases  ;  but  what  is  lost  in  quantity  is 
more  than  compensated  for  by  accuracy  and  wealth  of  detail. 
As  a  matter  of  fact,  although  I  have  had  access  to  several  thou- 
sands of  cases,  in  only  a  little  over  200  were  the  details  suffi- 
ciently complete  to  be  of  use. 

With  regard  to  this  morbid  neuropathic  heredit3^  the  following 
additional  facts  may  be  cited :  of  124  patients  with  neuropathic 
heredity,  it  was  present  in  the  direct  line  only  in  58  ;  in  the 
collaterals  only  in  26  ;  and  in  both  direct  and  collaterals  in  40 

2 


1 8  Mental  Deficiency 

cases.     It  was  present  on  the  paternal  side  only  in  6i ;  on  the 
maternal  only  in  39  ;  and  on  both  sides  in  24  cases. 

It  is  seen  from  these  latter  figures  that  paternal  is  more  common 
than  maternal  inheritance.  Voisin  found  the  reverse  to  be  the 
case.  It  is  therefore  probable  that  a  sufficiently  large  series. 
of  cases  would  show  that  there  was  little  difference  in  this 
respect.  In  my  cases  the  transmission  occurred  equally  to  the 
same  and  to  the  opposite  sex. 

2.  Alcoholism. 

This  is  the  hereditary  factor  next  in  importance,  and  in  my 
own  series  of  cases  a  pronounced  history  of  family  alcoholism 
occurred  in  no  less  than  46 '5  per  cent.  It  is  to  be  remarked, 
however,  that  in  five-sixths  of  these  definite  neuropathic  heredity 
was  present  in  addition  ;  whilst  in  most  of  the  remainder  there 
were  other  morbid  influences. 

The  results  obtained  by  other  inquirers  are  somewhat  divergent. 
Beach  and  Shuttleworth  found  a  history  of  alcoholism  in  but 
1638  per  cent,  of  their  cases  ;  Kerlin  (Philadelphia)  in  38  per 
cent.  ;  and  Bourneville  (Paris)  in  62  per  cent.  Howe  (America) 
found  that  in  nearly  50  per  cent,  of  idiots  the  parents  were 
habitual  drunkards.  On  the  other  hand,  Looft  (Norway)  found 
it  present  in  but  37  per  cent.,  and  Kind  (Hanover)  in  only 
II  per  cent. 

There  can  be  little  doubt  that  long-continued,  excessive 
indulgence  in  alchohol  has  a  considerable  effect  upon  the  germ  and 
sperm  cells,  and  that  it  results  in  an  impairment  of  the  nervous 
system  of  the  offspring.  In  fact,  f  believe  that  such  psychoses 
as  hysteria,  migraine,  epilepsy,  etc.,  are  often  due  to  this  cause.* 
In  my  experience,  however,  alcoholism  is  rarely  the  immediate 
and  sole_cause  of  amentia,  although  where  other  factors  exist — 
particularly  neuropathic  heredity — it  is  a  most  important  con- 
tributory agent. 

But  there  is  another  mode  of  action  which  has  to  be  con- 
sidered— namely,  the  direct  effect  of  alcohol  upon  the  embryo. 
This  is  not  hereditary,   but  environmental ;  it  will,  however, 

*  Interesting  evidence  on  this  point  is  furnished  by  a  laborious  research 
conducted  by  Dr.  Crothers  of  Connecticut,  U.S.A.,  and  published  in  the 
Quarterly  Journal  of  Inebriety,  January,  1901. 


Causation 


19 


be  convenient  to  refer  to  it  in  this  place.  The  ingestion  of 
alcohol  is  very  speedily  followed  by  its  appearance  in  the  blood, 
consequently  the  alcohol  imbibed  by  a  pregnant  woman  very 
soon  comes  into  close  contact  with  the  tissues  of  the  Embryo.  It 
has  been  conclusively  shown  by  numerous  experiments*  that 
alcohol  exerts  a  most  marked  baneful  influence  upon  growing 
protoplasm,  and  the  systematic  abuse  of  alcohol  during  gestation 
is  liable  to  be  followed  by  decidedly  injurious  consequences  to 
the  offspring.  These  consequences  are  often  widespread,  but 
?  ^  anomalies  of  mental  action  are  the  most  frequent,  as  they  are 
certainly  the  most  important.  Occasionally  actual  idiocy  may 
result,  of  which  several  instances  have  been  recorded. 

Some  authors  have  endowed  one  particular  moment — that  of 
(^once£tioit=^with  quite  phenomenal  possibilities ;  and  Langdon 
Down,  Sabatier,  Quatrefages,  Lucon,  Morel,  Bourneville,  and 
several  other  writers,  are  of  opinion  that  idiocy  is  a  common 
sequence  of  drunkenness  at  this  time.  Accurate  information  on 
such  a  point  is,  of  course,  very  difficult  to  obtain,  and  it  is  not 
easy  to  eliminate  other  factors.  Drunkenness  at  such  a  moment 
is  more  likely  to  be  an  incident  in  a  life  of  intemperance  than 
a  solitary  lapse,  and  in  many  cases  it  is  probably  actually  sympto- 
matic of  a  neuropathic  diathesis.  Perhaps  the  influence  of  this 
factor  per  se  is  best  judged  by  the  instances  mentioned  by 
Ireland,  t  in  which  in  some  parts  of  Scotland  whole  villages  of 
the  lower  classes  get  drunk  at  New  Year  time,  or  where  the 
herring  fishermen  have  a  carouse  upon  their  return  to  port. 
Dr.  Ireland  states  that  it  has  never  been  noticed  that  the  resulting 
children  are  idiotic.  I  have  histories  of  idiots  conceived  under 
such  circumstances,  but  so  I  have  of  normal  children  ;  and  my 

*  It  was  shown  by  Fere  of  Paris  that  the  effect  of  the  vapour  of 
alcohol  upon  incubating  eggs  was  to  produce  63  per  cent,  of  normal 
births,  16  per  cent,  of  incompletely  developed  embryos,  and  21  per  cent, 
of  monstrosities  and  chickens  of  "  idiotic  and  imbecile  grade."  If  the 
experiments  were  made  with  alcoholic  solutions  of  absinthe,  the  effects 
were  still  more  marked,  there  being  but  25  per  cent,  of  normal  births, 
31  per  cent,  of  incompletely  developed,  and  44  per  cent,  of  abnormal  and 
defective  chicks.      ("  Comptes  Rendus,  Societe  de  Biol.,"  Paris,  vol.  Hi.) 

For  further  particulars  as  to  the  effect  of  alcohol,  see  Horsley  and 
Sturge,  "  Alcohol  and  the  Human  Body,"  1907  ;  also  a  very  interesting 
paper  on  "The  Problem  of  Heredity,"  by  W.  L.  Andriezen, /owrwa/  of 
Mental  Science,  January,  1905. 

t  W.  W.  Ireland,  "  Mental  Affections  of  Children,"  1898. 

2—2 


20  Mental  Deficiency 

opinion  is  that,  whilst  this  may  be  a  cause  in  some  cases,  the 
number  of  such  is — in  this  country,  at  any  rate — exceedingly 
small. 

i,  3.  Tuberculosis. 

I  believe  that  this  factor  is  but  rarely  the  direct  and  sole  cause 
of  amentia  ;  but  my  observations  show  that,  like  alcoholism,  it 
has  a  very  important  indirect  and  contributory  influence.  Its 
indirect  effect  is  seen  in  its  undoubted  potency  to  produce  the 
milder  forms  of  nervous  instability  in  the  offspring,  such  as 
migraine,  hysteria,  and  mild  epilepsy  ;  whilst  its  importance  as 
a  contributory  agent  is  shown  by  the  large  proportion  of  aments 
who  come  of  a  tuberculous  stock.  I  found  that  in  the  families  of 
34  per  cent,  of  aments  there  was  a  pronounced  tendency  to 
tubercular  lesions.  Beach  and  Shuttleworth  found  the  same 
in  close  on  30  per  cent,  of  their  cases  ;  Langdon  Down  in  22*5  per 
cent.,  Kerlin  in  56  per  cent.  In  four-fifths  of  my  cases,  however, 
this  tuberculous  diathesis  was  associated  with  a  neuropathic 
inheritance,  and  in  the  remaining  fifth  other  conditions — usually 
alcoholism — were  also  present.  Some  additional  evidence  as 
to  the  prevalence  of  a  tubercular  diathesis  in  the  mentally 
defective  is  afforded  by  the  large  number  of  these  persons  who 
succumb  to  this  disease.  Ireland  estimates  the  proportion  as 
fully  two-thirds  of  all  cases,  and  although  in  many,  or  most  of 
them,  the  general  deficiency  in  mental  and  bodily  vigour  may 
increase  their  susceptibility  to  the  action  of  the  specific  bacillus, 
I  think  the  large  death-rate  from  this  cause  warrants  us  in 
saying  that  there  must  be  an  inherited  predisposition  beyond 
the  ordinary. 

I  regard  these  three  morbid  ancestral  conditions — namely, 
disease  of  the  nervous  system,  alcoholism,  and  consumption — as 
being  far  and  away  the  most  frequent  causes  of  mental  defect. 
The  two  latter  appear  to  me  to  be  rather  remote  than  immediate 
in  their  action,  their  effect  being  to  initiate  the  neuropathic 
diathesis,  which  (if  unchecked)  eventually  culminates  in  anientia. 
It  is  comparatively  rarely  that  they  give  rise  to  actual  mental 
deficiency  in  the  immediately  succeeding  generation,  although 
they  may  do  so  in  some  cases.  In  my  own  series  there  were 
7-5  per  cent,  in  whom  no  other  cause  was  discoverable.  In  four- 
fifths  of  these  the  ancestry  was  literally  saturated  with  both 


Causation  21 

alcohol  and  consumption,  in  the  remainder  with  alcohol  alone. 
Most  of  these  patients  suffered  from  a  mild  degree  of  imbecility 
accompanied  by  epilepsy. 

On  the  other  hand,  where  a  neuropathic  inheritance  exists  on 
one  side,  the  presence  of  either  of  these  factors  appears  to  exert 
a  most  potent  contributory  influence.  As  showing  the  extent  to 
which  they  occurred  in]combination,'it  may  be  stated  that,  of 
124  patients  coming  of  neuropathic  stock,  28  had  in  addition  an 
alcoholic,  and  15  a  tubercular,  heredity;  whilst  in  19  both  of 
these  contributory  causes  were  present. 


4.  Syphilid 

Mtst  observers  are  agreed  that  syphilis  ^lone  is  not  a  frequent 
cause  of  amentia.  Fletcher  Beach  found  it  present  in  but  i  -17  per 
cent,  of  the  2,400  pauper  aments  he  examined  from  the  London 
area.  Langdon  Down  and  Shuttleworth  found  it  in  about  2  per 
cent,  of  cases,  and  in  my  own  series  it  occurred  in  2*5  per  cent. 
It  is  probable,  as  stated  by  Mott,  that  '*  there  would  undoubtedly 
be  a  considerably  larger  proportion  of  derective  children  from 
this  cause  were  it  not  for  the  very  high  rate  of  sterility,  mis- 
carriages, stillborn  and  short-lived  offspring  that  it  produces." 

The  action  of  syphilis  in  these  cases  may  be  truly  hereditary — 
namely,  by  impairing  the  vitality  of  the  germ  or  sperm  cells,  so 
that  perfect  development  cannot  take  place.  Fournier*  has 
shown  that  this  devitalization  is  by  no  means  an  uncommon 
result,  but  inquiries  show  that  in  cases  of  amentia  there  are 
generally  other  factors,  especially  neuropathic  heredity,  present 
in  addition  to  the  syphilis. 

On  the  other  hand,  syphilis  may  be  *'  inherited  "  without 
being  hereditary  in  the  sense  in  which  we  have  been  speaking, 
and  cases  of  "  congenital  "  syphilis  are  of  this  nature.  The 
actual  disease  is  here"  transmitted  to  the  child  through  the 
maternal  tissues.  The  condition  is  not  truly  intrinsic,  but 
environmental ;  yet  we  may,  as  a  matter  of  convenience,  refer 
to  it  here.  Children  thus  suffering  from  inherited  syphilis 
present  the  characteristic  lesions  of  that  disease  ;  but  the  pro- 
portion who  are  in  consequence  mentally  defective  appears  to 

*  Fournier,  "  Les  Affections  Parasyphilitiques,"  1894.  See  also  Mott, 
"  Heredity  and  Disease,"  British  Medical  Journal,  October,  1905. 


22  Mental  Deficiency- 

be  small.  As  a  result  of  my  examination  of  over  i,ooo  idiots 
and  imbeciles  of  varying  grades  in  Darenth  Asylum,  I  found  only 
about  0*5  per  cent,  whose  condition  could  be  attributed  solely  to 
syphilis.  It  is  also  clear,  from  a  study  of  the  numerous  cases  of 
congenitaljues  which  may  be  seen  in  the  out-patient  department 
of  any  large  hospital,  as  well  as  from  the  number  of  adults 
marked  with  the  characteristic  signs,  that  a  normal  mental 
development  is  quite  compatible  with  the  existence  of  this  disease. 
"C  Where  amentia  does  result,  it  is  generally  because  other  factors 
Lare  present  in  addition.  \ 

It  has  been  suggested  by  Dr.  Sutherland  that  syphilis  is  a  fre- 
quent cause  of  that  variety  of  defect  known  as  '*  MQngolisuXr^ 
My  experience,  resulting  from  the  careful  investigation  of .  many 
family  histories  and  patients  of  this  type,  does  not  confirm  this 
view. 

Alcohol,  tubercle,  and  syphilis  are  probably  by  no  means 
the  only  poisons  which  have  a  devitalizing  effect  upon  the 
germ  and  sperm  cells,  and  which  therefore  contribute  to  arrest 
and  anomalies  of  development.  They  are,  however,  the  most 
prevalent,  and  on  that  account  the  most  important.  As  an 
example  of  the  action  of  other  poisons,  reference  may  be  made  to 
lead,  some  striking  figures  regarding  which  are  furnished  by 
Constantin  Paul.*  This  observer  relates  that  out  of  thirty-two 
pregnancies  in  which  the  father  suffered  from  lead-poisoning,  the 
mother  being  free  from  that  condition,  there  were  twelve  stillborn 
and  seventeen  deaths  under  the  age  of  three  years,  another  one 
dying  later  in  childhood  ;  whilst  only  two  were  found  to  be  alive, 
aged  twenty  years  and  twenty-one  months  respectively. 

5.  Consanguinity. 

The  statement  has  been  frequently  made  that  the  marriage 
of  near  blood  relations  is  attended  with  disastrous  results  to 
the  physical  and  mental  condition  of  the  offspring,  and  this 
factor  used  to  be  alleged,  and  is  now  considered  by  many  persons, 
as  a  prevalent  cause  of  idiocy.  Certainly  in  some  such  marriages 
the  consequences  upon  the  offspring  are  appalling,  as  has  been 
well  shown  by  numerous  writers.  On  the  other  hand,  there  are  - 
instances  where  repeated  intermarriage  has  taken  place  for  many 
*  Constantin  Paul,      Plumbism  and  the  Foetus,"  Paris,  1861. 


Causation 


23 


generations  without  the  sHghtest  untoward  result.  Thus,  Voisin, 
who  investigated  the  offspring  of  forty-six  consanguineous  mar- 
riages in  the  commune  of  Batz,  where  intermarrying  had  been 
the  rule  for  several  generations,  says  that  "  insanity,  idiocy,  and 
deaf -mutism  are  unknown  ";  and  the  same  author  could  not  find 
consanguinity  the  cause  of  mental  deficiency  in  a  single  case  at 
the  Bicetre  and  Salpetriere.  Huth*  also  is  of  opinion  that  this 
practice  is  not  attended  with  harm  if  the  family  is  healthy,  and 
instances  the  inhabitants  of  Pitcairn  and  Iceland  in  support  of 
his  statement.  George  Darwin |  arrived  at  a  similar  conclusion. 
The  crux  of  the  whole  question  is  the  presence  of  morbid  heredity, 
not  of  consanguinity,  and  I  believe  the  result  to  be  entirely 
dependent  upon  the  presence  or  absence  of  a  constitutional 
taint.  Should  such  be  present,  it  will,  of  course,  tend  to  be 
accentuated,  and  the  effect  upon  the  offspring  may  be  disastrous. 
In  its  absence,  however,  I  doubt  whether  any  untoward  result 
is  likely  to  follow,  and  I  certainly  do  not  think  that  amentia 
will  arise.  As  a  matter  of  fact,  a  considerable  amount  of  inter- 
marrying still  takes  place  in  certain  localities  of  our  own  country, 
such,  for  instance,  as  inaccessible  islands  in  the  North  of  Scot- 
land and  out-of-the-way  rural  districts ;  but  I  know  of  no  statistics 
showing  that  in  these  cases  it  has  been  responsible  per  se  for  the 
occurrence  of  mental  deficiency.  At  the  same  time  there  arc 
many  physiological  reasons  against  the  practice,  and  it  is  not  one 
to  be  advocated. 

In  my  opinion,  therefore,  the  statement  that  consanguinity  is, 
in  itself,  an  important  cause  of  amentia  is  one  not  supported  by 
facts.  In  my  own  series  of  cases  I  found  that  only  5  per  cent, 
of  defectives  were  the  offspring-  of  blood  relations,  and  in  all  of 
these  a  pronounced  neuropathic  heredity  was  present.  A  simi- 
larly small  percentage  is  revealed  by  several  other  inquirers. 
Thus,  Beach  and  Shuttleworth  found  consanguinity  in  4*2  per 
cent.,  Down  in  7  per  cent.,  Kerlin  in  7  per  cent.,  and,  in  fact, 
the  result  of  careful  research  is  decidedly  to  discount  this  factor 
as  a  cause  of  amentia.  Langdon  Down,  indeed,  says  :  "  I  am 
by  no  means  sure  that  by  a  judicious  selection  of  cousins  the  race 
might  not  be  improved." 

*  Alfred  Huth,  "  Marriage  of  Near  Kin,"  London,  1875. 
t  G.  Darwin,  Journal  of  the  Statistical  Society,  June,  1875. 


^     OF   THE 

UNIVERSITY 


24  Mental  Deficiency 

6.  Age  of  Parents. 

There  are  reasons  for  thinking  that  the  age  of  the  parents  at 
conception  is  not  without  influence  upon  the  vitaHty  of  the  child. 
Thus  Korosi,*  as  a  result  of  the  investigation  of  24,000  unselected 
individuals,  came  to  the  conclusion  that  the  children  of  fathers 
below  twenty  -and  above  forty  years  are  weaker  than  when  the 
fathers  are  between  these  ages  ;  also  that  the  children  of  mothers 
over  forty  years  of  age  are  weaker  than  those  born  when  the 
mother  is  below  this  age.  Matthews  Duncan f  was  of  opinion 
that  premature  and  late  marriage  were  influential  in  the  pro- 
duction of  idiocy,  and  Langdon  DownJ  found  that  in  23  per 
cent,  of  idiots  there  was  a  disparity  of  more  than  ten  years  in 
the  ages  of  the  parents.  Amongst  my  own  patients  a  similar 
disparity  existed  in  4  per  cent,  of  cases,  in  all  of  them  the  father 
being  the  elder.  In  one  case  the  difference  in  age  was  as  much 
as  thirty-two  years.  In  all  these  families,  however,  a  well- 
marked  neuropathic  diathesis  was  present,  and  as  I  have  know- 
ledge of  several  cases  in  which  a  similar  difference  existed  with- 
out morbid  heredity,  where  the  offspring  is  perfectly  healthy, 
I  am  of  opinion  that  the  influence  of  such  a  condition  is,  in  itself, 
really  infinitesimal. 

{B)  Causes  Extrinsic  to  the  Germinal  Plasm — Environment. 

The  abnormal  factors  of  the  environment  may  most  con- 
veniently be  referred  to  under  the  three  headings — Before,  During, 
and  After  Birth. 

Those  acting^  before  birth  are  mostly  referable  to  some  un- 
healthy mental  or  physical  condition  of  the  mQJ±L£i_during 
pregnancy,  although  an  actual  injury  to  the  foetus  may  also 
occur  during  this  time.  During  birth  they  chiefly  relate  to  the 
various  abnormalities  attending  labour,  and  in  this  place  refer- 
ence will  also  be  made  to  primogeniture  and  premature  birth. 
AjUr  hirih_J^  factors  are  either  traumatic,  toxiCr-convulsive, 
or  some  disturbance  profoundly  influeiicihg  nutrition. 

There  is  no"doubt  that  a  history  of  one  or  other  of  these  factors 

*  Korosi,  Transactions  of  the  International  Congress  of  Hygiene, 
London,  1891,  vol.  x. 

t  Matthews  Duncan,  Lancet,  January  and  March,  1883. 

X  Langdon  Down,  "  Notes  of  One  Thousand  Cases  of  Idiocy."         j_ 


Causation  25 

can  be  elicited  in  a  considerable  number  of  cases  of  amentia. 
In  my  own  series  of  cases  they  were  present  in  no  less  than 
65  per  cent.  There  is,  however,  much  difference  of  opinion  as 
to  their  importance  as  a  cause  of  this  condition. 


I.  Before  Birth. 

I.  Abnormal  Conditions  of  the  Mother  during  Pregnancy. — 
The  unhealthy  state  of  the  mother  may  be  either  menM  or 
■physical.  The  former  embraces  worry,  sudden  shock  or.  fright. 
and  the  much-debated  question  of  maternal  imf)ressions  ;  whilst 
the  latter  may  be  due  to  the  presence  of  actual  disease,  or  to  a 
general  state  of  imperfect  AgaMindependent  of  any  specific  illness. 
Perhaps  in  some  instances  these  physical  conditions  may 
operate  upon  the  germ  cells  before  conception,  but  it  is  con- 
venient to  refer  to  them  under  the  heading  of  environment. 

I  found  one  or  other  of  these  abnormal  conditions  to  be  present 
in  about  one-fifth  of  the  cases  I  examined,  but  in  most  of  them 
there  was,  in  addition,  a  pronounced  morbid  heredity,  generally 
insanity  or  epilepsy.  As  a  consequence  I  have  come  to  the 
conclusion  that,  although  these  conditions  may  have  an  im- 
portant contributory  influence,  it  is  with  extreme  rarity  that 
they  can  be  considered  to  be  the  sole  cause  of  mental  defect. 

I  am  of  opinion  that  the  bodily,  rather  than  the  mental,  state 
of  the  mother  is  of  most  importance  to  the  developing  embryo, 
and  a  condition  of  general  physical  prostration  or  malnutrition  is 
more  commonly  present  in  cases  of  amentia  than  is  actual  disease. 
In  poorer  people  especially  this  malnutrition  can  often  be  directly 
traced  to  an  insufficiency  of  food  during  this  period,  due  to  the 
fact  of  the  bread-winner  of  the  family  being  out  of  work,  although 
it  is  probable  that  frequently  recurring  pregnancies  may  so  lower 
the  mother's  vitality  as  to  produce  a  similar  result. 

I  have  already  stated  that  the  presence  of  alcoholism,  tuber- 
culosis, and  syphilis  in  the  mother  constitute  an  adverse  environ- 
ment, and  may  in  that  way  decidedly  interfere  with  the  normal 
development  of  the  offspring.  Other  poisons  may  so  act,  and 
one  of  the  chief  of  these  is  lead.  Rennert*  states  that  many  of 
the  women  employed  in  the  pottery  factories  of  Germany  suffer 

*  Rennert,  Americaii  Jounial  of  Obstetrics,  October,  1882. 


26  Mental  Deficiency 

from  a  form  of  plumbism,  which  gives  rise  to  frequent  abortions, 
deaf-mutes,  and  macrocephahcs.  It  is  possible  that  ecbohcs 
may  have  a  similar  effect,  and  it  is  even  stated  that  in  America 
the  use  of  these  drugs  is  responsible  for  a  considerable  number 
of  cases  of  feeble-mindedness.  Moreover,  the  influence  of  a  toxic 
environment  upon  the  offspring  has  been  experimentally  demon- 
strated by  Fere  in  the  interesting  series  of  investigations  upon 
eggs  already  referred  to.  It  must,  however,  be  emphasized  that 
cases  of  amentia  resulting  from  these  causes  are  relatively  rare, 
and  that  in  the  large  majority  of  defectives  an  abnormal  con- 
dition of  the  mother  during  pregnancy  has  a  contributory  or 
determining  influence  only. 

But  in  cases  in  which  hereditary  neuropathic  predisposition 
is  but  slight,  contributory  influences  of  this  kind  may  become 
of  considerable  importance,  and  may  make  all  the  difference 
between  a  development  of  the  nervous  system  compatible  with 
the  needs  of  everyday  life  and  one  of  mental  deficiency.  As 
will  presently  be  seen,  these  and  similar  contributory  factors 
explain  why  it  happens  that  an  idiot  may  be  born  into  a  family 
of  which  the  other  members  of  the  same  generation  show  no 
obvious  mental  or  physical  deterioration. 

Illegitimacy  has  been  credited  with  the  causation  of  amentia. 
It  is  no  doubt  responsible  for  a  very  high  proportion  of  infantile 
deaths,*  and  statistics  show  that  this  is  on  account  of  the  adverse 
environment  in  such  cases,  but  I  do  not  think  it  is  ever  in  itself 
a  direct  cause  of  mental  defect. 

With  regard  to  the  much-debated  question  of  maternal  im- 
pressions, without  entering  into  this  subject  in  any  detail,  it  can 
be  said  that  both  these  and  the  sudden  frights  and  shocks  which 
are  often  alleged  to  be  the  cause  of  the  patient's  condition  really 
have  very  little  influence.  So  far  I  have  been  unable  to  dis- 
cover a  single  case  of  this  nature  in  which  hereditary  influences 
(commonly  insanity)  were  not  forthcoming  upon  a  careful  inquiry 
into  the  antecedents,  so  that,  whilst  being  unable  to  deny  the 
possibility  of  amentia  resulting  from  such  conditions,  it  can  cer- 
tainly be  positively  affirmed  that  such  instances  are  exceedingly 
rare. 

An  instance  which  is  sometimes  quoted  in  support  of  the  influ- 

*  See  Dr.  Lankester's  report,  quoted  in  Newsholme's  "  Vital  Statistics." 


Causation  27 

ence  of  maternal  impressions  is  the  siege  of  Paris.  Legrand  du 
Saulle  says  :  "  Out  of  92  children  born  in  Paris  during  the  great 
siege  of  1870-71,  64  had  mental  and  physical  anomalies,  and  the 
remaining  28  were  weakly  ;  21  were  imbecile  or  idiotic,  and  8 
showed  moral  or  emotional  insanity."  But  may  it  not  be  that 
these  effects  were  the  result  of  the  ■^h^sical  condition  of  the 
mothers  attending  this  dreadful  time — of  the  environment  rather 
than  of  any  mental  impression  ? 

As  showing  what  little  real  effect  the  mother's  mental  state 
has  upon  the  child,  I  may  here  refer  to  the  case  of  children 
born  whilst,  or  shortly  after,  the  mother  was  insane.  This  is 
by  no  means  an  uncommon  event ;  in  fact,  a  certain  number  of 
children  are  born  every  year  within  lunatic  asylums,  and  I  have 
traced  the  subsequent  history  of  thirty-eight  of  these  up  to 
periods  at  which  any  mental  abnormality  would  have  been 
evident.  In  fourteen  of  these  women  "the  insanity  was  of  a 
temporary  nature,  due  solely  to  nervous  breakdown  at  a  trying 
period,  and  morbid  heredity  was  absent.  Out  of  the  fourteen 
children,  ten  were  alive  and  well  in  body  and  mind  at  ages  varying 
from  three  to  fifteen  years,  whilst  four  were  dead.  On  the  other 
hand,  in  twenty-four  women,  the  attack  of  insanity  was  accom- 
panied by  a  pronounced  morbid  inheritance.  Out  of  these 
children  only  three  were  alive  and  well,  whilst  twenty-one  had  suc- 
cumbed, all,  with  one  exception,  a  few  months  after  birth.  Owing 
to  the  great  difficulty  of  following  up  such  cases,  these  figures 
are  necessarily  small ;  but  I  cannot  do  other  than  regard  them 
as  additional  evidence  of  the  slight  effect  of  the  mental  state 
during  gestation,  and  of  the  important  influence  of  morbid 
heredity. 

2.  In^MJesJoJhe  Foetus. — In  a  few  cases  amentia  is  attributed 
to  an  injury  received  during  intra-uterine  existence,  but,  as  these 
in  no  way  differ  from  those  in  which  injury  is  inflicted  after  birth, 
it  will  be  better  to  consider  them  with  the  latter  group. 

2.  Du^mg^-BtEX]^ 

I.  AbiwmmlJjihQMZ^ — It  is  generally  considered  that  this  is 
a  very  important  and  frequent  cause  of  mental  deficiency.  Beach 
and  Shuttleworth  attribute  no  less  than  17-5  per  cent,  of  their 
cases  to  such  cause,  of  which  14*2  per  cent,  were  due  to  protracted 


2  8  Mental  Deficiency 

labour  causing  pressure,  and  33  per  cent,  to  instrumental  delivery. 
It  is  to  be  remembered,  however,  that  these  statistics  were  con- 
fined to  institution  cases,  and  I  believe  that  such  are  hardly 
representative  of  amentia  in  general .uJL*'^^'^^ ' 

Where  difficulty  in  parturition"  causes  mental  defect,  it  is 
because  a  gross  lesion  of  the  brain  has  been  produced ;  such 
cases  are  generally  of  a  severe  degree,  and  consequently  tend  to 
gravitate  to  the  special  institutions.  In  corroboration  of  this, 
I  found  that  a  history  of  these  factors  was  much  more  common 
among  the  severer  grades  at  Darenth  Asylum  than  amongst  the 
patients  in  the  London  County  asylums  ;  but  even  in  those  at 
Darenth  careful  inquiries  elicited  that  in  the  majority  pro- 
nounced morbid  heredity  was  also  present.  Out  of  18  per  cent, 
of  cases  in  which  I  obtained  a  history  of  abnormal  labour,  pre- 
cipitate labour  occurred  in  2  per  cent.,  protracted  labour  with 
asphyxia  in  14  per  cent.,  and  instrumental  delivery  in  2  per 
cent.  ;  but  in  only  one-ninth  of  these  was  there  no  neuropathic 
predisposition.  All  of  these  latter  were  cases  of  asphyxia 
neonatorum,  and  as  they  are  confirmed  epileptics,  it  is  probably 
largely  owing  to  the  convulsions  that  the  mental  arrest  is  due. 

I  am  therefore  of  opinion  that  the  importance  of  abnormalities 
of  labour  as  a  cause  of  amentia  has  been  much  overrated,  and 
that  the  total  number  of  cases  which  are  the  immediate  con- 
sequence of  these  conditions  is  relatively  very  small,  being 
probably  not  more  than  i  or  2  per  cent,  of  all  aments.  It  is  true 
that  the  parents  of  the  patients  are  generally  quite  satisfied  with 
this  explanation  ;  they  find  it  much  more  comforting  to  believe 
that  the  unfortunate  child  is  the  victim  of  some  extraneous 
factor  than  the  product  of  hereditary  taint  ;  but  I  am  con- 
vinced that,  if  careful  inquiries  are  made  into  the  family  histories 
of  these  cases,  pronounced  hereditary  tendency  will  be  found  in 
a  very  large  proportion.  On  the  other  hand,  there  can  be  no 
doubt  that  where  such  morbid  heredity  exists,  any  difficulty^ 
during  labotfr — and  especially  if  attended  with  aspltyxfe^^nl 
have  an  important  contributory  effect  ;  and  it  is  certainly 
responsible  for  many  of  the  gross  brain  lesions,  with  their  re- 
sulting paralyses  and  convulsions,  which  are  so  common  in  the 
more  severe  grades.  It  is  to  be  remarked  that  abnormal  presen- 
tations and  anomalies  of  labour  are  probably  of  much  greater 


Causation  29 

frequency  in  psychopathic  than  in  mentally  sound  women,  as 
also  with  defective  than  with  normal  children. 

Little,*  in  an  important  paper  published  in  the  year  1862, 
was  the  first  in  this  country  to  draw  attention  to  mental  and 
physical  defects  resulting  from  abnormalities  of  labour.  He 
collected  a  series  of  63  cases  presenting  various  defects  of  this 
kind,  the  most  common  cause  being  asphyxia  due  to  pro- 
tracted delivery  ;  but  he  himself  says  :  ''  It  is  obvious  that  the 
great  majority  of  stillborn  infants  whose  lives  are  saved  by  the 
attendant  accoucheur  recover  unharmed  from  that  condition  " — 
a  statement  which  has  since  been  fully  endorsed  by  many 
eminent  obstetricians,  and  which  is  confirmed  by  everyday 
experience.  It  is  indisputable  that  in  a  certain  small  percentage 
of  cases  in  w^hich  asphyxia  or  haemorrhage  occurs  some  degree  of 
paralysis  results — indeed,  this  condition  is  known  as  ''Little's 
disease  " — also  that  of  the  cases  so  affected  a  small  number  may 
show  mental  impairment.  Out  of  the  63  cases  of  lesions  col- 
lected by  Little,  however,  there  were  only  11  in  which  the 
intellect  suffered,  2  of  these  being  actually  idiotic,  and  the 
remaining  9  suffering  from  various  degrees  of  feeble-minded- 
ness.  In  all  his  cases  the  patients  were  seen  at  an  age  at  which 
mental  impairment  would  have  been  noticed  had  it  existed,  and 
in  some  of  those  who  were  physically  defective  the  mental 
capacity  is  described  as  being  beyond  the  average.  Unfortu- 
nately, Little  did  not  inquire  into  the  family  history  of  his  cases, 
but  his  paper  affords  no  evidence  that  amentia  is  at  all  a  common 
result  of  abnormality  of  labour.  In  this  connexion  it  ma}^  be 
remarked  that  it  is  recorded  of  Samuel  Johnson  that  "  he  was 
born  almost  dead,  and  did  not  cry  for  some  time." 

With  regard  to  instrumental  delivery,  we  have  only  to  con- 
sider the  number  of  children  who  are  delivered  by  forceps  every 
day,  and  the  fact  that  the  head  of  the  child  is  even  normally 
subjected  to  great  pressure  in  the  parturient  canal,  to  arriv^e  at 
the  conclusion  that  the  proper  use  of  the  forcep^can  play  no 
practical  part  in  the  production  of  amentia.  It  may  further  be 
remarked  that  artificial  compression  of  the  child's  head  after 
birth  has  been  long  practised  by  several  races  of  people,  and  is 
even  now  still  in  use  in  the  Toulouse  district  of  France,  without 

*  Little,  Teansactions  of  the  London  Obstetrical  Society,  1862. 


30  Mental  Deficiency 

any  apparent  evil  effects,  and  certainly  without  producing  idiocy. 
Dr.  Delisle*  says  that,  although  in  France  the  practice  is  slowly 
dying  out,  it  still  persists  to  a  surprising  extent.  He  finds, 
however,  that  it  shows  no  tendency  to  become  hereditarily  im- 
pressed upon  the  race  nor  is  there  any  sufficient  evidence  to 
support  the  belief  that  it  causes  either  any  arrest  of  physical 
or  mental  development,  or  any  unusual  tendency  to  insanity. 
Lastly,  Spiegelbergt  says  that  "the  indentations  and  depres- 
sions which  result  in  the  cranial  bones  from  pressure  have  a 
comparatively  unimportant  influence  on  the  children." 

2.  Primogenitiive. — It  is  said  that  first-born  children  are  more 
liable  to  be  mentally  defective  than  are  those  born  subsequently, 
and  this  is  attributed  partly  to  a  supposed  increased  mental 
instability  of  the  mother  during  a  first  pregnancy,  and  partly 
to  the  undoubted  fact  that  labour  is  more  protracted  in  pri- 
miparae.  But  it  has  already  been  seen  that  neither  the  mother's 
mental  state  nor  protracted  labour  really  have  very  much 
influence  upon  the  intellectual  status  of  the  child  in  the  absence 
of  neuropathic  predisposition,  so  that  the  question  of  primo- 
geniture as  a  cause  of  amentia  need  hardly  be  seriously  dis- 
cussed. As  a  matter  of  fact,  I  believe  the  statement  that  an 
undue  proportion  of  idiots  are  first-born  children  is  decidedly 
open  to  question,  and  my  own  experience  is  to  the  effect  that  it 
is  more  common  for  the  later-born,  and  not  the  first-born,  to  be 
affected.  In  those  families  in  which  there  is  a  pronounced 
tendency  to  mental  and  physical  degeneracy,  the  effects  usually 
appear  to  be  more  and  more  marked  upon  each  successive  child, 
and  often  enough  the  idiot  is  actually  the  last  born.  I  have 
notes  of  not  a  few  families  in  which  the  first  one  or  two  children 
presented  no  great  departure  from  the  normal ;  these  were 
followed  by  one  or  two  others  who  succumbed  to  ordinary 
children's  ailments,  from  which  healthy  children  would  probably 
have  recovered  ;  then  came  the  idiot,  in  some  cases  to  be 
succeeded  by  a  number  of  still-births. 

3.  Pr0mture  Birth. — Where  hereditary  predisposition  exists, 
it  is  probable  that  the  child  who  is  prematurely  born  will  have 

*  Delisle,   "Artificial  Deformity  of  the  Skull,"   Bull.  Soc.  d'Anth.  de 
Paris,  1902,  fas.  2. 

t  Spiegelberg,  "  Text-Book  of  Midwifery." 


Causation  31 

less  chance  of  attaining  complete  mental  development  than  will 
the  one  who  goes  to  full  term  ;  but  in  the  absence  of  other  factors 
I  do  not  believe  that  premature  birth  has  any  effect  upon  the 
resulting  mental  condition. 

3.  After  Birth. 

The  factors  acting  after  birth  which  are  capable  of  producing, 
or  assisting  in  the  production  of,  amentia  may  be  considered 
under  the  following  headings  : 

1.  Traumatic. 

2.  Toxic. 

3.  Epileptic  and  teething  convulsions. 

4.  Defects  of  nutrition. 

It  may  be  said  at  the  outset  that,  although  most  of  these 
conditions  may  give  rise  to  amentia  unaided,  the  number  of  cases 
solely  and  simply  due  to  them  is  relatively  small,  and  for  the 
most  part  their  influence  is  contributory  or  exciting  only. 

1.  Traumatic. — An  injury  to  the  child's  head  in  the  early 
months  of  life,  or  whilst  it  is  still  within  the  uterus,  is  a  frequently 
alleged  cause  of  mental  defect  ;  but  in  most  cases  careful  inquiry 
will  serve  to  show  the  extremely  trivial  nature  of  the  injury 
received,  and  will  make  it  abundantly  clear  that  it  could  have 
no  connexion  with  the  patient's  deficiency.  In  other  cases, 
however,  the  history — particularly  of  unconsciousness — leaves 
no  room  for  doubt  that  a  severe  trauma  has  been  inflicted, 
and  I  believe  that  in  a  small  number  of  cases  this  is  the  direct 
cause  of  amentia.  In  such  cases  it  is  probable  that  rupture  of 
vessels  has  taken  place,  leading  to  the  destruction  of  a  localized 
area  of  brain  tissue,  and  in  most  of  these  patients  the  amentia 
is  accompanied  by  epilepsy  or  paralysis. 

2.  Toxic. — In  a  certain  proportion  of  cases  of  acute  infectious 
disease  occurring  in  infancy,  such  as  scarlet  fever,  enteric,  whoop- 
ing-cough, diphtheria,  and  measles,  as  well  as  in  otitis  and 
rhinitis  and  acute  polio-encephalitis,  there  are  objective  signs 
that  a  cerebral  lesion  has  been  produced.  Perhaps  in  some 
of  these  affections  (particularly  pertussis)  the  change  may  be 
in  the  vessels  of  the  brain  or  its  meninges  ;  but  in  most  the 
symptoms  rather  point  to  a  direct  poisoning  of  the  brain  cells  ; 


z- 


32  Mental  Deficiency 

accordingly  I  have  grouped  them  together  as  "  toxic."  The 
majority  of  children  so  affected  die  ;  others  make  a  complete 
recovery  ;  whilst  in  a  few  others  death  does  not  take  place,  but 
a  permanent  legacy  remains  in  the  form  of  paralysis,  epilepsy,  or 
amentia.  I  shall  refer  to  these  cases  again  in  considering  the 
question  of  pathology,  but  here  it  may  be  stated  that,  although 
toxic  processes  of  this  kind  may  undoubtedly  produce  amentia, 
the  number  of  such  cases  is  relatively  small.  In  exceptional 
instances  the  amentia  may  be  caused  indirectly  through  ''  sense 
deprivation." 

It  is  probable  that  the  variety  of  amentia  known  as  "  infantile 
cerebral  degeneration  "  or  "  amaurotic  family  idiocy  "  is  really 
due  to  some  form  of  toxin,  although  the  pathogenesfeoT'teis 
disease  is  as  yet  very  obscure. 

Sunstroke  is  an  uncommon  cause  of  mental  defect,  but  I  have 
seen  three  cases  in  which  the  closest  inquiries  failed  to  reveal 
any  other  cause,  so  that  I  am  disposed  to  think  that  the  exposure 
of  a  young  infant  to  a  very  hot  sun  may  occasionally  produce  a 
cerebral  lesion  and  lead  to  an  arrest  of  development.  In  two  of 
the  cases  the  exposure  occurred  in  India ;  in  the  third,  in  this 
country  during  a  very  hot  summer,  and  all  of  them  were  attended 
with  unconsciousness. 

The  above  are  the  chief  etiological  factors  responsible  for 
the  gross  cerebral  lesions  which  sometimes  lead  to  amentia.  In 
addition,  cerebral  new  growths  may  occasionally  so  act. 

3.  Epileptic  and  Infantile  Convulsions. — Convulsions  of  some 
kind  or  other  are  amongst  the  most  frequently  alleged  causes  of 
amentia  ;  but  it  is  easy  to  mistake  effect  for  cause,  and  careful 
inquiries  show  the  number  of  aments  so  produced  to  be  relatively 
small. 

Severe  and  frequent  epilepsy  in  the  adult  often  leads  to  de- 
generation and  dementia,  and  in  infancy,  whilst  the  brain  is 
still  rapidly  growing,  it  may  cause  imperfect  development  and 
consequent  amentia.  But  such  cases  are  comparatively  in- 
frequent, and  in  all  probability  do  not  comprise  more  than  about 
3  or  4  per  cent,  of  all  aments. 

Infantile  convulsions,  particularly  those  occurring  during  den- 
tition, are  often  assumed  to  be  entirely  distinct  from  epilepsy, 
but  in  reality  there  is  no  clear  line  of  division  between  the  two. 


Causation 


33 


In  many,  perhaps  most,  cases  of  infantile  convulsions  the  history 
will  show  the  pr3sence  of  an  hereditary  predisposition,  and  in 
many  patients  they  recur  in  later  life  as  ordinary  idiopathic 
epilepsy.  Sir  William  Gowers  states  that  "  a  considerable 
number  of  cases  of  epilepsy  date  from  infantile  convulsions." 
In  the  presence  of  morbid  heredity,  it  is  often  exceedingly 
difficult  to  say  whether  convulsions  are  the  cause  of  the  mental 
deficiency,  or  merely  symptomatic  of  it,  but  my  own  experience  is 
that  true  "  eclampsic  "  amentia  is  a  comparatively  rare  con- 
dition. Some  further  remarks  on  the  relationship  existing 
between  convulsions  and  amentia  will  be  given  in  subsequent 
chapters. 

4.  Malnutrition. — There  can  be  no  doubt  that  the  general 
environment,  and  especially  the  quantity  and  quality  of  the  food, 
the  amount  of  fresh  air,  light,  warmth,  and  the  care  bestowed 
upon  the  growing  child,  have  an  important  influence  upon  his 
bodily  development.  This  is  well  shown  by  a  comparison  of  the 
physique  of  town  and  country  children.  But  the  same  does  not 
seem  to  hold  good  with  regard  to  mental  development.  Here 
sensory  stimulations  seem  to  be  almost  as  important  as  food,  and 
the  intellect  of  the  gamin  of  the  slums  is  often  vastly  superior 
to  that  of  the  lusty  country  clodhopper. 

In  some  instances,  as  will  be  seen  in  treating  of  mentally 
defective  children,  an  adverse  environment  gives  rise  to  delayed 
mental  development,  and  the  same  result  may  follow  serious 
ill-health  or  disease  ;  but  on  the  whole  it  may  be  said  that  these 
factors  have  comparatively  little  influence  in  producing  amentia 
in  the  absence  of  hereditary  predisposition.  Rickets  is  some- 
times the  accompaniment  of  mental  deficiency,  but  I  doubt 
whether  it  is  ever  its  cause.  One  variety  of  defect,  however — 
namely,  cretinism — is  undoubtedly  due  to  the  deprivation  of  a 
specific  nutritive  material. 

General  Considerations. 

Having  seen  what  are  the  chief  intrinsic  and  extrinsic  factors 
associated  with  amentia,  as  well  as  the  extent  to  which  they 
occur,  we  may  now  consider  the  manner  in  which  they  act. 

With  regard  to  these  two  groups,  it  is  clear  from  the  account 

3 


34  Mental  Deficiency   * 

already  given  that  a  history  of  one  or  other  factor  of  the  environ- 
ment (extrinsic)  is  found  in  a  very  considerable  proportion  of 
cases  (65  per  cent.) ;  and,  bearing  in  mind  that  evidence  of  this 
kind  is  much  easier  to  elicit  than  is  a  history  of  morbid  heredity, 
it  is  not  surprising  that  many  writers  have  attributed  great  im- 
portance to  these  external  factors.  At  first  sight  I  was  inclined 
to  do  so  myself,  and  it  was  only  when  I  found  how  often  pro- 
nounced morbid  heredity  lay  behind  that  I  came  to  a  different 
conclusion.  I  am  far  from  denying  that  the  environment,  even 
when  riiorbid  heredity  is  present,  has  no  effect.  Whether  the 
fertilized  ovum  be  inherently  defective  or  not,  it  is  evident  that 
its  development  may  be  interfered  with  by  injury  or  disease  ; 
also  that  it  must  be  to  a  considerable  extent  dependent  upon 
the  quantity  and  quality  of  the  nourishment  it  receives,  either 
whilst  within  or  without  the  uterus.  Consequently,  a  condition 
of  actual  disease,  ill-health,  or  starvation  of  the  mother  cannot 
but  be  injurious  to  the  growing  embryo ;  and  the  same  may  be 
said  of  the  improper  food,  impure  air,  deficient  light,  and  inade- 
quate sleep,  which  are  so  often  the  lot  of  young  children  in  our 
city  slums.  What  I  wish  to  point  out,  however,  is  that,  as  far 
as  my  experience  goes,  injurious  external  factors  of  themselves 
but  rarely  give  rise  to  mental  defect,  and  when  they  do  so  it  is 
usually  because  they  have  produced  a  gross  lesion  of  the  brain. 

The  result  of  my  inquiries  has  been  to  convince  me  of  the 
immense  importance  of  morbid  heredity  in  the  production 
of  amentia.  It  would,  of  course,  be  desirable  that  these 
statistics  should  be  compared  with  similar  ones  regarding  the 
mentally  normal  population.  As  far  as  I  am  aware,  none  such 
exist,  but  for  several  years  past  I  have  been  gathering  details 
from  hospital  and  private  patients,  and  I  am  fully  satisfied  that 
the  amount  of  morbid  heredity  is  absolutely  insignificant  in  the 
mentally  normal  as  compared  with  the  defective  population. 
Instances  of  an  ancestor  dying  of  consumption,  or  being  addicted 
to  drink,  or  even  being  epileptic  or  insane,  are  not  uncommon  ; 
but  it  is  decidedly  exceptional  to  find  definite  and  pronounced 
neuropathic  heredity  in  an  individual  of  normal  bodily  and 
mental  development.  Conversely,  the  number  of  cases  of  pro- 
nounced mental  defect  (in  which  a  tolerably  complete  family 
history  is  forthcoming)  which  can  be  solely  attributed  to  extrinsic 


Causation 


35 


or  environmental  causes  is  probably  not  more  than  20  per  cent, 
at  the  very  outside. 

So  much,  then,  for  the  relative  importance  of  the  two  classes 
of  factors.  Let  us  now  consider  the  modus  operandi  of  each  in 
bringing  about  arrest  of  cerebral  development. 

I.  Intrinsic  or  Hereditary  Influences. 

It  would  obviously  be  out  of  place  to  enter  into  any  detailed 
account  of  the  various  theories  regarding  heredity,  but  there  are 
some  points  which  have  such  an  important  bearing  upon  the 
causation  of  amentia  that  they  must  be  alluded  to.  Now,  it  is 
contended  by  Weismann*  that  the  environment  has  practically 
no  effect  upon  the  germinal  plasm,  but  that  this  latter  is  handed 
down  unaltered  through  all  the  ages,  and  simply  transmits 
qualities  or  possibilities  of  development  which  have  existed  ab 
initio.  Upon  this  assumption  disease  and  unhealthy  surround- 
ings, however  much  they  may  affect  the  individual,  are  power- 
less to  influence  posterity,  and  '*  degeneracy  "  is  an  utter  myth. 
I  am  decidedly  of  opinion,  however,  that  this  theory  is  contra- 
dicted by  the  facts  of  everyday  life,  and  I  believe  that  the 
germinal  plasm  is  capable  of  modification  by  the  environment, 
and  that  the  alteration  so  produced  may  very  materially  affect 
subsequent  generations. 

Weismann's  doctrine  apparently  receives  a  good  deal  of  sup- 
port from  the  statement  that  "  acquired  properties  are  not  trans- 
mitted," and  there  is  no  doubt  that  of  certain  acquirements  this 
statement  is  true.  The  examples  generally  adduced  are  such 
mutilations  as  the  docking  of  dogs'  tails,  the  nose-slitting  of 
savages,  systematic  compression  of  the  cranium,  and,  above 
all,  the  practice  of  circumcision.  It  is  true  that  mutilations  of 
this  kind  have  been  performed  systematically  upon  generation 
after  generation,  and  yet  they  show  no  tendency  to  be  trans- 
mitted to  the  offspring  or  to  impress  themselves  upon  posterity. 
Acquired  local  properties  of  this  kind,  •  therefore,  are  certainly 
not  transmitted. 

But  there  is  another  kind  of  modification  which  stands  on 
quite  a  different  footing,  inasmuch  as  it  is  not  local,  but  general 

*  Weismann,  "  The  Germ  Plasm,"  and  other  works. 

3—2 


36  Mental  Deficiency 

and  universal  in  its  extent.  I  refer  to  the  effect  of  certain 
diseases.  In  some  diseases  the  pathological  change  is  almost  as 
localized  as  are  the  mutilations  just  referred  to ;  but  in  others 
there  is  abundant  evidence  that  the  whole  organism  is  affected. 
For  instance,  in  such  conditions  as  extensive  j)ulmonaiy_tiiher- 
culosis,  chronic  alcoholism,  acuterheumatism,  syphilis  ^diabetes, 
pyaemia,  anaemia^  and  possibly  als5  in^_sarneT^RS£S_QlIca^cer  ^^^ 
otheFwastmg  diseases^  it  is  clear  from  both  clinical  and  patho- 
logicaLejcperience  that  not  a  local,  but  a  g^eneral.  change  has  been 
produced.  Can  we  imagine  thatt,  amid  all  this  disturbance  of 
metabolism,  the  germ  and  sperm  cells  remain  unaffected,  that 
they  lead  a  charmed  hfe,  utterly  indifferent  alike  to  the  effect  of 
poison  or  the  quantity  and  quality  of  their  food  ?  Assuredly  not. 
The  germinal  plasm,  endowed  as  it  is  with  functions  of  the  utmost 
importance,  is  yet  in  its  origin  but  a  highly  specialized  somatic 
tissue.  Like  other  tissues,  it  is  dependent  for  its  growth  and 
development  upon  the  blood-supply,  and,  also  like  them,  it  is  sus- 
ceptible to  the  action  of  poison.  Under  certain  abnormal  con- 
ditions its  maturation  may  be  delayed,  and  there  are  many  facts, 
some  of  which  have  been  cited  in  previous  pages,  which  con- 
clusively demonstrate  that  it  may  be  injured  by  certain  bodily 
diseases. 

It  is  on  this  point  that  the  experience  of  the  physician  is  dia- 
metrically opposed  to  the  doctrine  of  Weismann.  One  observes 
in  medical  practice  so  much  difference  between  the  mental  and 
bodily  vigour  of  those  children  who  are  the  offspring  of  pro- 
nounced alcoholic  or  phthisical  fathers,  as  compared  with 
children  of  healthy  parentage,  that  it  is  impossible  to  avoid 
the  conclusion  that  a  serious  deterioration  of  the  germinal  plasm 
has  taken  place.  Not  only  the  subject  of  mental  deficiency, 
but  everyday  experience  supplies  ample  evidence  of  the  im- 
portance of  morbid  heredity  upon  offspring,  and,  however  much 
the  theorist  may  ignore  its  influence  the  physician  is  unable 
to  do  so. 

I  think,  therefore,  that  it  cannot  be  questioned  that  the  ger- 
minal plasm  shares  in  those  alterations  of  the  bodily  protoplasm 
which  result  from  disease  and  environment.  According  as  this  is 
favourable  or  unfavourable,  the  modification  will  be  progressive 
or  retrogressive  ;  consequently,  each  individual  is  a  potent  influ- 


Causation  37 

ence  for  good  or  ill  in  the  development  of  the  race.     The  environ- '' 
ment  of  to-day  will  become  the  heredity  of  to-morrow,  and  the 
statement  that  the  sins  of  the  fathers  are  visited  upon  the  children 
unto   the  third   and  fourth  generation  is    an   undoubted   and 
important  physiological  truth. 

With  regard  to  the  causation  of  amentia,  I  beheve  that  there 
are  certain  diseases  which  bring  about  a  deterioration  of  the 

germ  plasm.      The  chief  of  these   are  alci^hnliam   nnH   ransmmp- 
tion,   although  it  is  probaby  that  nthpr  prn'sr^ns^  S^XUrI  j^X£ass^s 

and  many  factors^of  modern  life,  may,  by  low-en'ng  the  general_ 
vitality,  produce  a  similar_£f£££L  In  consequence,  there  result^ 
a  pathological  change  in  th^^t  part  of  thp  offspring  which  is  at 
on^^ej-he  most  elaborate,  the  most  vulnerable,  and  of  most 
recent  development — namely,  the  cerebral  cortex.  This  change 
consists  in  a  diminished  control  of  the  higher,  and  increased 
excitability  of  the  lower,  centres,  and  is  manifested  clinically  as 
neurasthenia,  hysteria,  migraine,  and  the  milder  forms  of  epilepsy. 
We  may  say  that  a  neuropath  has  been  created.  Should  the 
adverse  environment  continue,  or  should  such  a  person  marry  one 
similarly  tainted,  then  the  nervous  instability  becomes  accentu- 
ated in  the  following  generation,  and  insanity,  the  graver  forms 
of  epilepsy,  and  early  dementia,  make  their  appearance.  If  the 
process  is  further  continued,  the  third  generation  will  be  charac- 
terized by  a  tendency  to  imperfection  of  anatomical  development, 
and  there  will  be  a  strong  probability  of  one  or  more  children 
suffering  from  amentia  ;  should  the  morbid  heredity  be  accom- 
panied by  any  injurious  factor  of  the  environment  (such  as  those 
we  have  described),  this  probability,  will  become  a  tolerable 
certainty.  Degeneracy-is-hcro  well  oatabliGbed,  and  the  well- 
known  "  gfigmafaj^rp  iisiinlly  ahnnHanf  Finally,  complete- 
sterility  appears,  and  the  farniMybprrmiP<;  PYt-;r..-f       Fnr  fVik  fr>rm^ 

of^mentia  duetojieredjiafylnfluen^  I  have  proposedjhe  term 

PRIMARY. 


It  is  not  suggested,  of  course,  that  the  three  grades  of  mental 
disease  above  described  are  necessarily  restricted  to  three  suc- 
cessive generations.  All  the  degrees  may  exist,  and  frequently 
do,  amongst  members  of  one  and  the  same  generation.  Neither 
do  I  wish  to  infer  that  the  neuropathic  heritage  always  cul- 
minates in  amentia  in  the  third  generation.     It  may  be  so 


38  Mental  Deficiency 

modified  by  the  admixture  of  fresh  blood  that  this  end  may  be 
much  longer  delayed  ;  it  may,  indeed,  even  be  eradicated  in 
some  instances.  On  the  other  hand,  it  occasionally  happens 
that  idiocy  of  the  grossest  type  JM^lts  from  the  presence  of 
alcoholism  and  consumption  in  the:^mediate  ancestors  without 
any  intermediate  abnormality  of  the  nervo^^system  having 
been  produced.  This,  however,  is  exceptio^^-and  I  believe 
that  the  outline  given  above  is,  on  the  whole,  aJBrably  accurate 
picture  of  the  successive  steps  in  the  production  of  amentia.  In 
many  of  the  families  of  whom  I  have  histories  it  is  actually 
possible  .to  trace  this  downward  march,  and  further  evidence  to 
the  same  effect  is  afforded  by  statistic^  regarding  the  etiology 
of  the  other  mental  affections.  For  instance,  in  persons  suffer- 
ing from  migraine,  neurasthenia,  and  hysteria,  it  is  uncommon 
to  find  marked  ancestral  nervous  or  psychic  disturbance,  but 
a  history  of  alcoholism  and  phthisis,  as  well  as  of  modes  of 
living  attended  with  severe  nervous  stress  and  strain,  is  fre- 
quent. In  the  milder  forms  of  epilepsy  morbid  neuropathic 
heredity  becomes  more  marked,  and  in  the  severer  forms  of  this 
affection  it  is  present,  according  to  Sir  William  Gowers,  in  about 
35  per  cent,  of  cases.  In  persons  suffering  from  insanity  the 
morbid  heredity  rises  to  50  or  60  per  cent.,*  whilst  in  amentia, 
as  we  have  seen,  it  is  present  in  80  per  cent,  of  cases: 

These  figures  well  show  the  gradual  accumulation  of  roorbid 
jieredity  which  lies  behind  the  different  grades  of  rriental  dis- 
ability, as  well  as  the  potency  of  the  hereditary  factor  in  the 
causation  of  amentia.  We  may,  indeed,  say  of  this  latter  affec- 
tion that  it  is  the  final  manifestation  of  a  progressive  psycho- 
pathic diathesis. 

As  throwing  some  further  light  upon  amentia  from  this  aspect, 
it  may  not  be  out  of  place  to  refer  to  the  contemporaries  of  these 
persons.  Whilst  inquiring  into  the  causes  of  amentia,  I  took  the 
trouble  to  ascertain  the  number  and  condition  of  all  the  brothers " 
and  sisters  of  150  patients.  I  divided  these  into  two  classes, 
which  were  designated  "satisfactory"  and  "unsatisfactory." 
The  satisfactory  group  comprised  all  those  who  were  said  to  be 
healthy  in  mind  and  body,  and  were  able  to  support  themselves. 

*  J.    S.    Bolton,    "Amentia    and    Dementia,"    Mott's    "Archives    of 
Neurology,"  vol.  ii. 


/5'^/7p^ 


Causation 


39 


The  unsatisfactory  consisted,  in  addition  to  those  prematurely 
dead,  of  those  who  were  either  mentally  affected,  or  were  suffering 
from  marked  and  permanent  ill-health,  or  were  leading  a  life  of 
vagabondage  or  crime.  Such  details  were,  of  course,  difficult 
to  get,  and  as  the  valuation  was  generally  that  of  the  parents, 
the  figures  are  almost  certainly  more  favourable  to  the  class  than 
the  real  facts.     These  figures  are  shown  in  the  following  table  : 


TABLE  VL 

Showing  the  Condition  of  150  Aments  with  their  Brothers  and 

Sisters. 

{In  the  150  families  there  were  1,269  children  horn.) 


Unsatisfactory. 

1 
Satisfactory. 

{a)  Born  dead 

{&)  Since  died  : 
Under  i  year 
,,     3  years 
,,    10     ,, 
,,   20     „ 
Over  20     ,, 

(c)  Mentally  a£Eect( 

{d)  Diseased,  pauj 
1                 criminals 

.      138^ 
.      107 

.        37 
8 

.        25J 
id       .. 
)ers,    or 

170 

-315 

245 
83 

Said    by    parents    to    be 
mentally     and     bodily 
healthy 456 

Total 

813 

Total            ..        ..     456 

1 

1,269 

Some  points  in  this  table  are  worthy  of  note.  Firstly,  the  large 
number  of  children  born.  According  to  the  Fortieth  Annual 
Report  of  the  Registrar-General  (1876),  the  average  number  of 
births  to  a  marriage  in  England  and  Wales  is  4-63.  The  number 
of  children  in  150  normal  families  would  therefore  be  694  ; 
whereas  in  the  families  we  are  now  considering  the  number  born 
alive  is  1,099,  ^^  ^^  average  of  "^'^  per  family.  Secondly,  the 
large  number  of  still-births.  No  precise  data  exist  with  regard 
to  the  number  of  these  in  the  normal  population,  as  they  are 


40  Mental  Deficiency 

unregistered,  but  Farr  and  Newsholme  estimate  them  at  about 
4  per  cent,  of  the  total  births.  If  these  famihes  were  normal,  we 
should  therefore  expect  to  have  44  children  stillborn,  whereas 
we  find  170.  Thirdly,  the  mortality  of  these  children  is  even 
more  remarkable.  According  to  the  life  table  of  the  Registrar- 
General,  based  upon  the  years  1881-1890  (Supplement  to  Fifty- 
fifth  Annual  Report,  1895), 

Had  the  1,099  Children  belonged  to  the  "Average  "  Whereas  there  were' 

Class,  there  would  have  been  surviving —  surviving — 

At  end  of  i  year        . .         937        . .  . .  . .       961 

3  years      ..         864       ..  ..  ..       854 

„     10      „  ..         823 817 

„       ,,     20      „  . .         800        . .  . .  . .       809 

In  other  words,  the  mortality  is  practically  identical  with  the 
normal. 

I  do  not  wish  to  press  the  point  unduly,  because  the  number 
dealt  with  is  but  small.  Statistics  of  this  kind  are  exceedingly 
difficult  to  obtain,  and  I  know  of  no  others  at  present  existing  ; 
but  if  further  observations  should  confirm  these  here  given,  it 
would  follow  that,  although  the  progeny  of  neuropaths  are 
greatly  in  excess  of  those  born  of  the  average  population,  there 
is,  as  a  whole,  no  corresponding  excess  of  mortality  ;  and  this 
in  spite  of  the  fact  that,  as  we  shall  presently  see,  the  expectation 
of  life  of  those  who  are  actually  mentally  deficient  is  sub- 
normal. Even  assuming  that  the  456  brothers  and  sisters  of 
these  aments  are  really  sound  in  body  and  mind,  as  stated  by 
their  parents  (which,  however,  I  greatly  doubt),  it  is  to  be  re- 
membered that  they  come  of  a  pronounced  morbid  stock,  and 
are  not  only  capable  of,  but  exceedingly  likely  to,  transmit  the 
taint  to  a  subsequent  generation.  In  fact,  it  is  in  regard  to  these 
rather  than  the  actual  aments,  that  the  greatest  danger  of 
propagation  lies. 

The  following  family  history  charts  afford  graphic  illustrations 
of  many  of  the  points  referred  to. 

In  them  amentia,  insanity,  or  epilepsy,  is  shown  as  #  ; 
alcoholism,  tuberculosis,  general  ill-health,  neuroses,  and  prema- 
ture death,  as  ^  ;  whilst  persons  presumably  healthy,  dying 
from  natural  causes,  or  of  whom  no  information  is  obtainable, 
are  shown  as  O. 


Causation 


41 


CHART  I. 

SHOWING  GOOD  HEREDITY  CONTAMINATED  BY  SLIGHT 
ALCOHOLIC  HEREDITY  AND  TOWN  LIFE. 


Countrjr    , 


7o<V/l 


OtO 


hhihi 


All  SOL  d  tobt,  Ataithy 


6 


Difc/i2 
Consumption     2         Cor-surnpCu 


•I" 


Case  No.  131,  W.  J.  G. 


CHART  n. 


i 


SHOWING  GOOD  HEREDITY  CONTAMINATED  BY  MORBID 
HEREDITY. 


ar^_ 


/fo  tn/Or/77aftc?/t 


ry 


VI 


X      i     i?     J^     Jf    J^     J^ 

6  ®  ®  o  •  ®  o 


/frailly    Simcfr>  -^  //eaii?^      -^i    5iiUJ>orn  \  S3il(ii>cr/; 
ft 


Case  No.  10,  A.  C. 


42 


Mental  Deficiency 


CHART  HI. 

SHOWING  GOOD  HEREDITY  CONTAMINATED  BY  INSANE 
HEREDITY. 


d-       £ 


•tO      O-tO 

:d  az     £)iear30  £)cecl 73    /Leeds's 


Z>ied  az 
1  /asylum 


i^eebCtrAfiria^e  <J  ■ 


6Z  /lU  /lUyir  ^^ e-a-iCAy 


2.  3  [^  \S         W 


I 


Case  No.  5,  /.  W.  J. 


CHART  IV. 

SHOWING  THE  EFFECT  OF  INSANfe  +  PHTHISICAL  HEREDITY 


/isyfo,- 


P~Y^        Z>c^^^.. 


Uhh>_ 


Cczu..     ur^^^o^^^--'^'"/'^'^       -^.><f3/L^ff2V.^1.U  ^^i'-'^r. 


Z>eac/'  Z>fec/c 


Otseaae 


^ 


z 


/*V^«  ,  \ 


i 


7 


I3. 


Case  No.  99,  F.  W. 


Causation 


43 


CHART  V. 

SHOWING  EFFECT  OF  ALCOHOLIC  AND  INSANE  INHERITANCE 
+  PHTHISICAL  INHERITANCE. 


i66666666. 


/^deo/e  ^,S(N   nicd 


Case  No.  174,  C.  B. 


CHART  VI. 

SHOWING  THE  EFFECT  OF  DOUBLE  MORBID  HEREDITY. 


■^^^j  ^^      ^^^9f\^^ 


^ceai  0/  Con: 


n^eo 


Vp        U        La     J/-5    J/*'    \pr      L^ 

o • ®  poo • 


?  ?s  W  ^s 

^  ?fi.  .;^.^  u 


l€iyi 


Case  No.  9,  S.  V. 


44 


Mental  Deficiency 


CHART  VII. 

SHOWING  THE  EFFECT  OF  DOUBLE  MORBID  HEREDITY. 


\?c 

fl7 


'^y- 


.    I    ^^     ■  ^ 

Case  No.  83,  W.  A.  M. 


I 


CHART  VIII. 

SHOWING  THE  EFFECT  OF  A  DOUBLE  INSANE  INHERITANCE 

+  SYPHILIS. 


ll  11  li  II      is 


3:J.  2^^.    ^i    5::5 


^•^ 


CaseJNo,  97,  P.  W. 


Causation 


45 


CHART  IX. 

SHOWING  THE  EFFECT  OF  CONSANGUINITY  WITH  A  TENDENCY 
TO  VASCULAR  LESIONS  OF  THE  BRAIN. 


I 


^UU^ 


Ab  en/or-fri  aft  on      /:::>^ira/^Z  <^ 


yfsyiT'uL 


^s^ 


Case  No.  70,  F.  E.  V. 


We  must  now  refer  to  another  type  of  case  which  at  first  sight, 
appears  to  be  quite  distinct  from  the  one  just  described,  inas- 
much as  the  patient  may  be  the  only  one  of  the  family  showing 
any  sign  of  deterioration,  his  brothers  and  sisters  being  well 
developed  in  body  and  mind.  Similar  hereditary  influences 
exist  here  also,  though  not  in  such  marked_  degree,  and  it  is  in 
these  cases  that  they  are  mostly  present  on  one  side  only. 
Evidently  in  these  instances,  however,  the  condition  cannot  be 
attributed  entirely  to  defects  in  the  germinal  plasm,  as  in  that 
case  other  members  of  the  family  would  also  show  signs  of 
defective  development  ;  the  question  therefore  arises  as  to  why 
one  alone  should  be  affected. 

It  is  under  these  circumstances  that  I  believe  the  condition  of 
the  mother  during  gestation  to  be  of  most  vital  importance  to  the 
child  ;  obviously  it  is  a  difficult  matter  always  to  obtain  precise 
and  accurate  information  on  this  point,  but  I  have  been  much 
struck  by  the  fact  that  it  is  just  in  these — what  one  might  call 
sporadic — cases  of  idiocy  that  nearly  all  the  instances  of  abnormal 
condition  of  the  mother  during  pregnancy  have  occurred.   These 


46  Mental  Deficiency 


conditions  have  already  been  discussed,  and  it  will  be  sufficient 
to  note  here  that  the  one  most  frequently  associated  with  the 
birth  of  an  ament  is  a  state  of  general  ill-health  and  exhaustion, 
in  the  poorer  classes  often  accompanied  by  a  deficiency  of  proper 
food.  In  several  cases  it  has  happened  that  during  this  time 
the  father  was  out  of  work. 

Apparently,  under  these  less-pronounced  conditions  of  here- 
ditary predisposition,  the  germ  plasm,  although  to  a  certain 
extent  vitiated,  is  still  capable  of  proceeding  to  the  perfect 
structural  development  of  the  embryo,  provided  no  untoward 
circumstances  intervene  to  further  embarrass  its  growth  ;  but 
should  there  happen  at  this  time  any  deterioration  in  the  health 
of  the  mother,  whereby  the  blood  supplying  the  rapidly  growing 
ovum  is  considerably  modified  in  its  nutritive  qualities,  then 
incomplete  development  is  very  likely  to  happen.  As  far  as 
my  experience  goes,  the  physical  condition  of  the  mother  is  of 
far  more  importance  than  her  mental  state,  except  in  the  cases 
in  which  this  may  modify  the  physical  condition.  '      ? 

In  other  instances  the  same  result  is  attained  by  a  somewhat 
different  contributing  or,  as  it  may  be  termed,  exciting  factor. 
One/fairly  common  such  is  premature  birth  ;  if  by  any  unfortu- 
nate chance  this  should  happen  where  there  are  already  present 
p  edisposing  factors,  even  if  slight,  the  child  is  extremely  likely 
to  show  some  mental  deterioration  as  compared  with  his  brothers 
and  sisters.  In  other  cases  prolonged  labour,  attended  with 
more  or  less  asphyxia,  may  act  in  the  same  manner  ;  the  tem- 
porary obstruction  of  the  cerebral  circulation  need  not  be 
enough  to  give  rise  to  any  actual  lesion,  or  in  a  healthy  child 
to  produce  any  damage  whatever,  but  in  the  present  instance 
it  is  all  that  is  required  to  interfere  with  the  perfect  development 
of  the  nerve  cells,  and  some  degree  of  weakmindedness  is  the 
result. 

In  the  same  way  act  some  of  the  factors  occurring  after  birth, 
such  as  trauma,  convulsions,  rickets,  infectious  fevers,  men- 
ingitis, etc.  It  has  already  been  seen  that  in  the  larger  proportion 
of  these  cases  ancestral  defects  are  present,  and  the  exciting 
factor  probably  acts  by  causing  a  derangement  of  the  cerebral 
circulation  or  metabolism  from  which  the  nerve  cells  are  unable 
to  recover. 


Causation 


47 


It  is  necessary  to  bear  in  mind  that  in  the  majority  of  cases 
of  amentia  factors  such  as  the  above  are  only  accessory,  and  that 
the  real  origin  of  the  condition  lies  in  the  defect  of  the  germinal 
plasm,  the  result  of  morbid  heredity. 

The  term  developmental  was  applied  to  such  cases  by  Langdon 
Down,  but  in  view  of  their  inherent  defect  it  might  be  preferable 
to  refer  to  them  as  instances  of  delayed  primary  amentia. 

2.  Extrinsic  or  Environmental  Causes. 

It  has  been  seen  that,  although  adverse  conditions  of  the 
environment  are  present  in  a  considerable  number  of  cases  of 
amentia,  the  proportion  in  which  they  are  the  direct  and  sole 
cause  is  relatively  small — probably  at  the  most  not  more  than 
15  to  20  per  cent.  To  this  extent,  however,  the  environment 
does  seem  capable  of  producing  amentia,  although  in  many  in- 
stances this  is  but  the  incidental  phase  of  a  process  which  is  really 
degenerative  and  of  which  the  end  is  dementia.  As  such  cases 
are  entirely  independent  of  morbid  heredity  and  of  any  inherent 
defects  of  the  germinal  plasm,  I  have  proposed  to  call  this  variety 
SECONDARY  amentia.  I  have  already  enumerated  these  factors, 
and  since  many  of  them  are  pathological  processes  which  result 
in  a  gross  lesion  of  the  brain,  it  will  be  more  convenient  to 
describe  the  manner  of  their  action  together  with  their  clinical 
characteristics.  A  few,  however,  give  rise  to  a  general  arrest 
of  development  without  any  naked-eye  lesion,  and  these  may 
briefly  be  referred  to  in  this  place. 

Under  normal  conditions  the  brain  of  the  child  grows  with 
extreme  rapidity  during  the  first  few  years  of  life.  This  is  in 
consequence  of  its  inherent  capacity  for  growth  plus  the  stimula- 
tion of  sensory  impressions  and  the  presence  of  an  adequate 
quantity  and  quality  of  blood.  This  inherent  capacity  may  be 
normal,  but  the  necessary  stimulation  or  food  so  deficient  that 
the  gradual  unfolding  of  the  mental  faculties  does  not  take 
place,  or  takes  place  so  tardily  that  some  degree  of  backwardness 
is  the  result.  Cases  of  this  kind,  in  which  development  is 
delayed,  are  extremely  common,  and  it  usually  happens  that 
upon  the  removal  of  the  cause  mental  expansion  rapidly  ensues. 
Should  the  adverse  conditions  continue  sufficiently  long,  however, 


48  Mental  Deficiency 

the  brain  cells  seem  in  some  cases  unable  to  recover  ;  the  mind 
never  makes  up  the  lost  ground,  and  some  degree  of  mental 
deficiency  is  the  result.  In  my  experience  actual  idiocy  is  never 
caused  in  this  way,  and  the  resulting  defect  is  of  comparatively 
mild  degree  only  ;  it  is  nevertheless  a  true  amentia.  I  do  not 
think  that  cases  of  this  kind  are  very  common,  but  they  form  a 
certain  percentage  of  the  adult  feeble-minded  and  of  mentally 
defective  school-children,  particularly  in  the  large  towns.  The 
cause  seems  usually  to  be  that  combination  of  factors — drink, 
dirt,  and  depravity — which  go  to  make  up  slum  life  in  its  worst 
form. 

With  regard  to  the  influence  of  slum  life  and  all  its  associated 
conditions  in  producing  amentia,  it  is  necessary  to  sound  a  note 
of  warning.  It  does  happen  sometimes  that  the  real  mental 
defectives  of  our  large  towns  hail  from  the  slums,  although  I  do 
not  think  such  is  disproportionately  the  case.  Still,  a  sufficient 
number  of  defective  children  come  from  such  areas  to  make  the 
superficial  inquirer,  content  with  that  which  is  apparent,  jump 
to  the  conclusion  that  the  pernicious  environment  is  therefore 
the  cause  of  their  defect.  My  own  inquiries  have  convinced  me 
that  in  the  great  majority  of  these  slum  cases  there  is  pronounced 
morbid  heredity,  and  that  their  environment  is  not  the  cause, 
but  the  result,  of  that  heredity.  The  neuropath  is  one  who  as 
at  an  economic  disadvantage  in  the  struggle  for  existence.  He 
frequently  finds  it  difficult  to  hold  his  place,  and  he  is  often 
possessed  of  careless,  improvident,  and  intemperate  propensities, 
which  cause  him  to  fritter  away  the  money  he  does  earn.  He  is 
on  the  down  grade.  No  wonder,  then,  that  he  drifts  to  the 
slums. 

Factors  of  Causation  in  Regard  to  Local  Variations  of 
Incidence. 

Before  concluding  this  account  of  causation,  it  is  necessary  to 
refer  to  the  connexion  existing  between  certain  etiological  factors 
and  local  variations  in  the  prevalence  of  amentia. 

We  have  already  seen  (Chapter  II.)  that  the  incidence  of 
amentia  is  not  uniform  throughout  the  country,  but  that  in  some 
localities  it  is  relatively  much  higher,  and  in  others  much  lower, 
than  the  mean  average.     Into  the  cause  of  this  inequality  I  do 


Causation 


49 


not  propose  to  enter,  for  it  is  but  part  of  a  similar  variation  in  the 
incidence  of  mental  disease  in  general,  and  is  therefore  beyond 
the  scope  of  our  subject.  But  there  are  certain  variations  in  the 
incidence  of  amentia  relative  to  other  forms  of  mental  disease, 
and  in  the  incidence  of  the  degrees  of  amentia  relative  to  one 
another,  which  are  so  closely  connected  with  the  question  of 
causation  that  they  must  be  referred  to. 

The  Incidence  of  Amentia  relative  to  Insanity. — ^The  statistics 
of  the  Royal  Commission  show  that,  broadly  speaking, 
insanity  is  more  characteristic  of  the  urban  and  industrial,  and 
amentia  of  the  rural,  populations  of  this  country.  We  have 
already  seen  that  the  causes  of  these  two  conditions  are  identical 
in  kind — namely,  morbid  neuropathic  heredity — but  that  they 
differ  in  degree,  inasmuch  as  the  heredity  is  usually  more  pro- 
nounced in  amentia  than  in  insanity.  Now,  the  towns  have  been 
built  up  and  are  being  steadily  increased  by  the  immigration  of 
persons  from  the  country,  and  it  is  justifiable  to  conclude  that 
the  persons  so  migrating  will  possess  the  qualities  of  initiative, 
enterprise,  and  mental  vigour  in  a  higher  degree  than  those  who 
are  content  to  remain  upon  the  land — that,  in  short,  a  compara- 
tively smaller  proportion  of  them  will  come  of  a  pronounced 
neuropathic  stock.  This  process  inevitably  tends  to  the  accumu- 
lation in  the  rural  districts  of  those  most  saturated  with  morbid 
heredity — a  state  of  affairs  which  is  often  accentuated  by 
intermarrying,  and  so  the  conditions  in  these  areas  become 
more  and  more  favourable  to  the  production  of  actual  mental 
defect.  On  the  other  hand,  in  our  towns  and  densely  packed 
industrial  centres  competition  is  keen,  the  stresses  and  strains  of 
life  are  severe,  alcoholism  is  rife,  consumption  is  very  prevalent, 
narrow  streets  are  densely  packed  with  overcrowded  houses, 
women  advanced  in  pregnancy  continue  to  work  in  the  mills 
and  factories,  infants  who  should  be  at  the  breast  are  reared 
artificially,  and,  in  short,  all  the  conditions  are  present  to  pro- 
duce an  instability  of  the  higher  parts  of  the  nervous  system — 
the  precursor  of  insanity.  This,  in  subsequent  generations, 
leads  to  actual  defect  of  structure  and  consequent  amentia,  but 
the  constant  immigration  drags  fresh  blood  into  the  vortex,  and 
tends  to  make  insanity  rather  than  amentia  the  prevailing 
type  of  mental  abnormality. 

4 


CO  Mental  Deficiency 

-^•^he  Relative  Incidence  of  the  Different  Degrees  of  Amentia. 

— As  has  been  shown  in  Chapter  11. ,  not  only  is  amentia 
absolutely  more  prevalent  in  rural  than  in  urban  districts, 
but  the  grosser  degrees  of  defect  are  relatively  in  excess  also  ; 
whilst  in  the  towns  mentally  defective  children  are  relatively 
and  absolutely  more  prevalent  than  in  the  country.  I  am  of 
opinion  that  there  are  three  chief  factors  of  town  life  which  tend 
to  bring  about  this  result — namely  (i)  a  lessened  production, 

(2)  an  increased  destruction  of  the  more  severe  grades  of  defect, 
and  (3)  the  presence  in  the  towns  of  cases  of  delayed  development 
which  simulate  mental  defect,  and  so^  cause  an  apparent  increase 
of  mild  deficiency. 

(i)  Lessened  Production  of  Severe  Defect :  This  is  due  to  the 
same  causes  which  bring  about  a  diminished  incidence  of  amentia 
generally — namely,  a  lessened  neuropathic  heredity  in  the  town 
dwellers.  (2)  Increased  Destruction  of  Severe  Defect :  I  am 
unable  to  give  any  statistical  proof  of  this,  but  I  think  it  is  pos- 
sible that  the  relatively  higher  infantile  mortality  of  the  towns 
may  be  not  without  effect  in  causing  a  diminution  of  the  worst 
grades  of  defect  in  these  situations,  since  the  mortality  of  aments 
would  seem  to  be  directly  proportionate  to  the  degree  of  defect. 

(3)  It  has  already  been  remarked  that  a  small  proportion  of  cases 
of  secondary  amentia  are  the  result  of  a  faulty  environment, 
and  this  I  believe  to  be  more  prevalent  in  town  than  country. 
As  we  shall  see,  however,  in  considering  mentally  defective  chil- 
dren, there  is  a  condition  of  delayed  development  which  is  very 
much  more  common  in  densely  congested  areas,  and  which' 
simulates  real  amentia  very  closely^  I  believe  this  is  responsible 
in  no  slight  degree  for  the  apparent  increase  of  the  juvenile 
feeble-minded  in  towns.  In  corroboration  of  this  is  the  fact  that 
in  the  towns  there  is  no  relative  increase  of  the  adult  feeble- 
minded, even  when  it  is  remembered  that  a  small  proportion  of 
those  actually  bom  in  the  towns  are  gradually  squeezed  further 
afield  in  the  struggle  for  existence. 


OF    THE 

UNIVERSITY 

OF 


CHAPTER   IV 

PATHOLOGY 

Before  discussing  the  pathology  of  amentia,  it  will  be  an  ad- 
vantage to  allude  to  the  salient  features  in  the  development  of 
the  cells  of  the  cerebral  cortex. 

Development  of  the  Normal  Brain. 

The  first  indication  of  the  brain  is  seen  very  shortly  after 
fertilization  of  the  germ  cell,  and  consists  in  an  expansion  of  the/ 
nntrnor  ond  ni  fhojnidimrntnT}^  ripinnlxord  to  form  four  primary 
cerebral  vesicles.  It  is  by  a  series  of  elaborate  infoldings  of 
these  vesiclesTand  by  the  multiplication  around  them  of  the 
ceUs  composing  their  walls,  that  cerebral  development  takes 
place.  By  the  time  the  embryo  is  six  months  old  the  brain 
has  assumed  the  general  shape  of  the  adult,  although  there  is 
as  yet  a  complete  absence  of  all  those  secondary  fissures  and 
convolutions  which  are  such  a  characteristic  feature  of  the  fully 
developed  organ. 

At  birth  many  of  these  convolutions  are  present,  and  the 
brain  weighs*  from  280  to  330  grammes.  During  the  first  six 
months  of  life  growth  is  exceedingly  rapid,  the  weight  of  the 
brain  at  the  end  of  this  time  being  more  than  double  what  it 
was  at  birth — namely,  from  600  to  680  grammes.  By  the  end 
of  the  first  year  the  weight  has  reached  about  750  grammes, 
and  from  this  onward  it  still  continues  to  grow  until  the  age  of 
twelve  or  fourteen  years,  when  its  average  weight  is  1,150 
grammes  in  the  female  and  1,300  grammes  in  the  male.  A 
further  slight  increase  takes  place  during  the  next  seven  years, 

*  According  to  R.  Boyd,  Phil,  Trans.,  i860. 

51  4—2 


52  Mental  Deficiency 

and  at  the  age  of  twenty-one  the  brain  has  attained  the  weight 
of  1,244  grammes  in  the  female  and  1,374  grammes  in  the  male. 
From  this  period  growth  is  very  slow,  until,  according  to  Broca 
and  Peacock,  the  maximum  average  weight  of  1,269  grammes 
(45  ounces)  in  the  female  and  1,421  grammes  (50  ounces)  in  the 
male  is  attained  between  twenty-five  and  thirty-five  years  of  age. 

The  progressive  increase  in  size  and  weight  is  due,  firstly,  to 
the  rapid  multiplication,  and  secondly,  to  the  individual, 
development,  of  the  nerve  cells.  These  arise  from  the  cells  lining 
the  floor  of  the  primitive  cerebral  vesicles,  and  at  first  they  are 
of  one  uniform  indifferent  type.  Subsequently,  however,  differen- 
tiation occurs,  and  features  appear  which  are  characteristic,  and 
which  persist  throughout  life.  It  is  as  a  result  of  this  differentia- 
tion that  the  brain  cortex  acquires  its  peculiar  laminated  ap- 
pearance. Coincident  with  lamination  delicate  ^otojpj^asmic 
processes  arise  from  these  nerve  cells,  and,  pursuing  definite  direc- 
tions throughout  the  cerebral  mass,  constitute  the  association  and 
projection  systems  of  fibres.  The  former  serve  to  link  together  in 
the  most  complicated  manner  all  parts  of  the  brain  ;  they  also 
compose  the  great  association  centres  of  Flechsig ;  the  latter  are 
the  pathways  by  which  the  brain  is  connected  with  the  various 
parts  of  the  body.  , 

Development  does  not  proceed  simultaneously  in  all  parts  of 
the  brain.  The  nerve  cells  of  certain  areas  reach  maturity  much 
earlier  than  do  those  elsewhere,  and  the  frontal  and  parietal 
regions,  which  there  is  good  reason  for  thinking~afe  those  most 
concerned  with  the  highest  intellectual  functions,  are  the  last  to 
acquire  their  mature  characteristics.  In  the  frontal  lobes  of  the 
seven-months  embryo  lamination  has  not  yet  appeared,  and 
the  cells  are  of  a  uniform  undifferentiated  type  (neuroblasts). 
These  are  small  round  cells  with  a  close  and  readily  stainable 
reticulum,  but  quite  devoid  of  processes,  and  they  lie  embedded 
in  a  matrix  which,  in  the  hardened  and  stained  section,  some- 
what resembles  the  grain  of  marble.  In  the  eight-months 
embryo  the  neuroblasts  are  somewhat  larger,  the  reticulum  is 
less  close  and  has  less  affinity  for  stain,  but  there  are  as  yet  no 
definite  processes.  At  this  age  it  is  possible  to  make  out  the 
beginning  of  lamination  in  this  region  of  the  cortex.  In  the  child 
of  two  weeks  old  (extra-uterine)  the  cells  have  made  a  consider- 


Pathology  53 

able  advance,  and  they  are  now  readily  recognizable  as  nerve 
cells.  A  cell  body  is  present,  although  the  protoplasm  of  this 
differs  greatly  from  the  mature  cell,  being  very  vacuola^d,  and 
liable  to  break  away  from  the  nucleus.  At  this  age  also  the 
cells  of  the  pyramidal  layer  possess  an  apical  process,  •  and  occa- 
sionally other  processes  are  present  ;  but  the  apical  one  is  always 
the  best  developed,  and  appears  to  be  the  first  formed.  Finally, 
a  few  years  after  birth  the  cell  has  assumed  its  mature  character, 
and  possesses  axons,  dendrons,  and  gemmules.  In  other  regions 
of  the  brain  development  takes  place  earlier,  and  in  the  motor 
area  of  the  eight-months  embryo  medium-sized  pyramidal  and 
also  Betz'  cells  are  readily  recognizable. 

The  processes  of  the  fully  developed  nerve  cells  communi- 
cate with  one  another  (physiologically,  if  not  anatomically)  in 
an  exceedingly  complicated  ,net\york,  forming  the  bands  and 
systems  of  association  fibres  already  mentioned.  It  is  by 
means  of  them  that  nervous  impulses  travel  to  and  from 
all  parts  of  the  cerebro-spinal  system,  and  it  has  even  been 
suggested  that  the  nerve  cell  is  of  secondary  importance,  and 
only  serves  the  purposes  of  nutrition.  However  this  may  be, 
there  is  a  definite  relation  between  the  appearance  of  the  cell 
as  seen  under  the  microscope  and  the  state  of  the  fibre,  and 
the  condition  of  the  cells  forms  a  convenient  and  reliable  index 
of  the  presence  •f  disease. 

There  can  be  no  doubt  that  the  number  and  complexity  of  the 
cell  processes,  particularly  those  forming  the  association  systems, 
are  intimately  connected  with  the  degree  and  complexity  of  cere- 
bral activity,  and  it  is  highly  probable  that  the  intellectual  expan-., 
-SioiL- which  takes  place  after  puberty  is  due  to  their  numerical 
increase  and  the  elaboration  of  their  connexions.  It  has,  indeed, 
been  shown  by  Kaes*  that  a  progressive  increase  in  these  fibres 
can  be  demonstrated  up  to  the  middle  period  of  life,  after  which 
he  states  that  growth  ceases  and  a  gradual  diminution  takes 
place. 

Finally,  to  complete  this  brief  resume,  it  may  be  said  that 
the  nerve  cells  and  fibres  are  imbedded  in  a  network  of  supporting 
tissue  (neuroglia  cells  and  their  processes),  encased  in  a  series 
of   delicate   connective-tissue   membranes — the   meninges — and 

*   Kaes,  Monatsschrift  filr  Psychiatrie  und  Neiirolgie,  1897. 


54  Mental  Deficiency 


the  whole  organ  permeated  by  a  dense  ramification  of  blood- 
vessels. 

Whatever  may  be  the  relation  of  mind  to  brain,  it  is  now 
fully  recognized  that  the  manifestation  of  mental  activity  is 
indissolubly  connected  with  the  cells._pj  tlie..xer.ebraI_CQrtex. 
Mind. develops  pari  passu  with  their  growth,  and  fails  with 
their  decay.  Dementia  is  coincident  with  their  degeneration 
and  death,  and,  as  will  presently  be  shown,  amentia  is  associated 
with  their  incomplete  development. 

It  is  apparent  from  this  outline  of  cerebral  development 
that  the  period. of.  greatest  growth  is  that  between  the  first 
^appearance  of  the  primitive  brain  and  the  end  of  the  sixth 
month  of  extra-uterine  life  ;  consequently,  it  is  during  this 
period  that  the  demands  upon  the  environment  are  greatest, 
and  that  any  adverse  factor  will  be  most  severely  felt.  This 
entirely  accords  with  the  general  experience  that,  wjiere  secondary 
amentia  occurs,  it  is  the  result  of  an  adverse  environment  during 
the  early  months  of  life.  The  mental  development  which  takes 
place  after  puberty  appears  to  be  the  result  of  the  elaboration 
of  association  systems,  and  although,  theoretically,  developmental 
arrest  might  occur  at  this  time,  such  would  but  rarely  be  likely 
to  result  in  any  pronounced  deficiency.  On  the  other  hand,  in 
cases  of  primary  amentia,  the  condition  is  rather  one  of  a  general 
inability  to  develop  than  of  an  arrest  of  development,  and  the 
cause  is  in  existence  anterior  to  the  very  beginning  of  embryonic 
existence. 

THE  PATHOLOGY  OF  AMENTIA. 

Many  mistaken  notions  still  exist  with  regard  to  the  patho- 
logy of  amentia.  As  we  shall  presently  see,  in  a  very  con- 
siderable number  of  these  patients,  particularly  the  lower  grades, 
there  exist  gross  abnormalities  of  brain  structure,  or  severe  and 
extensive  morbid  conditions,  which  are  visible  to  the  naked  eye. 
Accordingly,  it  was  not  unnatural  that  the  earlier  observers, 
examining  isolated  cases  in  the  days  when  much  less  was  known 
about  the  structure  of  the  nervous  system  than  is  the  case  at 
present,  should  conclude  that  in  these  various  anomalies  they 
saw  the  fons  et  origo  of  the  mental  defect.  As  a  consequence, 
amentia  was  variously  attributed  to  the  presence  of  porencephaly, 


Pathology  55 


hemiatrophy^  microgyria,  and  the  like.  These  views  cannot  be 
held  to-day.  In  the  first  place,  it  has  been  abundantly  shown 
that  such  conditions  may  exist  without  any  mental  defect  or 
deterioration  whatever  ;  whilst,  secondly,  an  increased  knowledge 
of  the  structure  of  the  nervous  system,  and  particularly  of  the 
nerve  cell,  together  with  a  greatly  improved  technique,  has 
clearly  demonstrated  the  existence  of  important  cellular  changg;^,. 
in  amentia. 

In  support  of  the  statement  that  these  gross  conditions  cannot 
really  be  the  cause  of  mental  defect,  the  following  observations 
may  be  cited  :  About  thirty  cases  have  been  recorded  of  absence 
or  deficiency  of  the  corpus  callosum,  most  of  them  in  idiots,  yet 
Nobiling-Jolly,  Eichler,  and  Klob  have  each  recorded  a  similar 
case  in  which  there  was  no  mental  peculiarity.  Likewise  with 
another  frequent  accompaniment  of  amentia — porencephaly. 
Several  cases  have  been  described  in  which  a  large  cavity  existed 
in  one  hemisphere,  and  yet  there  was  little  or  no  appreciable 
mental  change.  Schroeder  van  der  Kolk*  mentions  a  number 
of  instances  tending  to  show  that  a  large  proportion  of  one  hemi- 
sphere may  be  diseased,  and  yet  the  patient  show  no  mental 
impairment.  Finally,  with  regard  to  another  condition — hydro- 
cephalus— Freud  f  states  it  to  be  an  undoubted  fact  that  severe 
hydrocephalus  may  exist  witlwu±__an}L_^a,ralytic  symptoms ; 
whilst  ZieglerJ  states  that  such  malformations,  or  even  still 
greater  defects,  may  exist  in  the  brain,  though  during  life  there 
was  nothing  whatever  to  indicate  their  presence. 

We  cannot  but  conclude,  therefore,  that  although  these  gross 
changes  are  frequently  associated  with  amentia,  they  are  not^ 
essential  to  that  .condition,  and  in  discussing  the  question  of 
pathogenesis  we  must  be  careful  clearly  to  distinguish  between 
what  is  essential  and  what  is  only  accidental. 

At  the  same  time  it  is  undeniable  that  gross  malformations 
and  coarse  lesions  are  much  commoner  in  the  epileptic  and 
mentally  defective  than  in  normal  persons,  and  it  is  easy  to 
understand,  from  the  description  which  has  been  given  of  the 
causation  and  hereditary  predisposition  of  these  persons,  that 

*  Schroeder  van  der  Kolk,  Sydenham  Society  Transactions,  1861. 
t  Freud,  "  Infantile  Cerebral  Lahmung,"  Wien,  1897. 
X  Ziegler,  "  Text-Book  of  Special  Pathology,"  1896. 


56  Mental  Deficiency- 

such  should  be  the  case.  On  the  other  hand,  there  is  no  doubt 
that  certain  morbid  processes  may,  even  in  the  previously  healthy 
brain,  produce  such  an  arrest  of  neuronic  development  as  to 
bring  about  amentia. 

The  essential  basis  of  amentia  is  an  imperfect  or  arrested 
development  of  the  cerebral  neurones,  a  fact  which  is  now 
established  beyond  doubt  by  careful  microscopical  examina- 
tions conducted  by  numerous  competent  observers.  This  morbid 
state  of  the  neurones  is  brought  about  by  the  causes  which  have 
already  been  described  in  Chapter  II.  Accordingly,  I  shall  first 
of  all  describe  these  histological  changes,  relegating  the  various 
gross  anomalies  and  diseased  conditions  to  a  second  place. 


The  Histology  of  Primary  Amentia. 

Nerve  Cells  of  the  Brain  Cortex. — As  compared  with  the  nerve 
cells  of  the  healthy  brain,  those  of  the  ament  are  characterized 
by  the  following  conditions  :  (i)  N.unierical  deficiency  ;  (2)  ir- 
regular arrangement  ;  (3)  imperfect  development  of  individual 
cells.;  and  on  the  whole  it  may  be  stated  that  the  amount  of 
change  discoverable  by  the  microscope  is  directly  proportionate 
to  the  degree  of  mental  deficiency  present  during  life. 

1.  Numerical  Deficiency. — Although  an  actual  enumeration 
of  the  nerve  cells  present  in  these  cases  cannot  be  made,  I  am 
convinced,  from  the  careful  examination  of  a  large  number  of 
sections,  that  the  cells  composing  the  grey  matter  of  the  cerebral 
cortex  are  decidedly  fewer  than  in  the  normal  brain.  In 
many  cases  this  paucity  of  cells  produces  a  decrease  in  the 
thickness  of  the  cortical  grey  matter  which  is  obvious  to  the 
naked  eye  (see  Fig.  9,  p.  63.  Further,  although  the  cells  of  all 
the  layers  are  fewer  than  normal,  it  is  the  small  and  medium- 
sized  pyramids  which  are  most  diminished  in  number.  Ham- 
marberg,  as  the  result  of  a  most  elaborate  and  caLreful  series 
of  observations,  arrived  at  a  similar  conclusion. 

2.  Irregular  Arrangement. — Hammarberg*  states  that  the 
arrangement  of  the  cortical  cells  in  amentia  does  not  differ  from 
the  normal ;  but  my  own  experience,  as  also  that  of  several  other 

*  Hammarberg,  "  Studien  uber  Klinik  und  Pathologic  der  Idiotic," 
Upsala,  1895. 


p 


Pathology  57 

observers,  is  to  tne  effect  that  an  irregular  and  haphazard 
arrangement  is  very  characteristic  of  this  condition.  The  pyra- 
'  midal  cells  show  the  most  change,  although  this,  of  course,  may 
be  simply  due  to  the  fact  that  the  form  of  these  cells  renders 
any  irregularity  more  apparent.  Throughout  the  brain  there 
are  in  this  layer  numbers  of  cells  lying  horizontally,  obliquely, 
or  completely  upside  down,  even  where  there  is  no  accompanying 
sclerosis,  and  where  sclerosis  is  present  the  irregularity  is  often 
extreme. 

3.  Imperfect  Development. — As  early  as  1879  Bevan  Lewis* 
drew  attention  to  the  presence,  in  certain  forms  of  amentia,  of 
incompletely  developed  nerve  cells,  and  similar  cells  were  present 
in  cases  which  I  examined.  When  stained  by  Nissl's  method 
they  have  the  following  characteristics :  The  nucleus  is  large  and 
ovoid  in  shape ;  the  nuclear  membrane  and  intra-nuclear  network 
are  very  distinct.  The  nucleolus  is  often  eccentric,  so  that  in 
some  sections  it  cannot  be  seen.  The  cell  outline  is  distinct, 
but,  instead  of  being  pyramidal,  it  is  globular  or  pyriform  in 
shape,  and  angles  are  completely  wanting.  The  processes  of  the 
cell  are  exceedingly  few,  and  in  many  instances  one  only  can  be 
seen  (see  Plate  I.,  Fig.  4).  This  paucity  of  dendrons  and  also 
of  gemmules  is  still  more  evident  in  sections  stained  by  the  silver 
method. 

I  think  it  cannot  be  doubted  that  the  conditions  here  described 
are  due  to  incomplete  development.  I  have  never  seen  such 
cells  in  any  human  brain  other  than  that  of  an  ament ;  it  is,  how- 
ever, interesting  to  note  that,  according  to  Bevan  Lewis,  similar 
cells^exist  normally  in  the  second  and  third  layers  of  the  cerebral 
cortex  of  the  ape.  Bevan  Lewis  was  only  able  to  discover  these 
immature  cells  in  cases  of  amentia  complicated  by  epilepsy, 
and  he  thought  they  did  not  occur  in  pure  amentia  ;  but  I  have 
seen  them  in  cases  in  which  epilepsy  was  absent. 

In  addition  to  the  above,  the  cerebral  cortex  of  the  pronounced 
ament  nearly  always  contains  a  large  number  of  other  cells  whose 
development  is  even  less  complete,  and  which  closely  resemble 
the  undifferentiated  neuroblasts  already  described  as  composing 
the  normal  frontal  cortex  up  to  the  eighth  month  of  embryonic 

*  Bevan  Lewis,  "  Text-Book  of  Mental  Diseases,"  1899  ;  also  Brain, 
October,  1879. 


5^  Mental  Deficiency 

existence.  In  these  there  is  practically  no  cell  body,  or  at  most 
a  few  irregular  protoplasmic  strands  ;  the  nucleus  is  large  and 
globular,  the  intra-nuclear  network  very  distinct,  and  often  dis- 
posed as  several  fine  lines  which  divide  the  nucleus  into  com- 
partments. In  fact,  they  are  undifferentiated -and-undeveloped-, 
jieuroblasts,  and  in  areas  of  localized  agenesis^such,  for  instance, 
as  are  seen  in  microgyria — there  is  often  no  other  kind  of  cell  to 
be  seen  (see  Plate  I.,  Fig.  i). 

There  is  another  condition  of  the  cortical  cells  which  is  exceed- 
ingly common  in  these  cases — namely,  pigrnentation.  This  does 
not  occur  in  the  immature  cells  above  described,  and  is  chiefly 
seen  in  the  deeper  pyramidal  layer,  in  which  it  is  often  a  very 
marked  feature.  The  pigment  is  generally  situated  at  one  angle 
of  the  cell,  away  from  the  nucleus,  but  at  times  it  is  so  abundant 
as  almost  completely  to  fill  the  cell  (see  Plate  I.,  Fig.  7).  It  is 
yellow  in  colour  in  Nissl  or  polychrome  sections,  but  appears 
dark  brown  or  almost  black  in  those  stained  with  Marchi's  fluid, 
and  hence  gives  to  these  sections  a  most  striking  appearance. 
In  several  of  my  cases  it  was  particularly  pronounced  in  the  cells 
of  the  hippocampus  (see  Plate  I.,  Fig.  8).  The  exact  nature  and 
significance  of  this  pigment  is  unknown,  though  the  reaction  with 
Marchi's  fluid  would  suggest  that  it  was  of  a  fatty  nature.  A 
similar  pigmentation,  but  to  nothing  like  the  same  extent,  is 
frequently  found  in  the  central  nervous  system  of  patients  who^ 
have  suffered  from  chronic  nervous  disease  (e.g.,  disseminated 
sclerosis,  amyotrophic  lateral  sclerosis,  progressive  muscular 
atrophy,  chronic  insanity,  etc.).  Its  occurrence  in  these  condi- 
tions as  well  as  in  aments  would  suggest  that  it  is  an  indication 
of  defective  metabolism,  in  which  the  anabolic  processes  cannot 
keep  pace  with  the  katabolic.  The  pigment  is  nearly  always 
associated  with  a  diminution  in  the  number  and  size  of  the  Nissl 
bodies. 

Nerve  Fibres  of  the  Brain  Cortex. — The  bands  of  tangentially 
coursing  fibres  ^comprising  the  association  systems  show  a 
very  defimle  diminution  in  cases  of  severe  amentia,  so  great, 
indeed,  as  often  to  be  apparent  to  the  naked  eye.  Gene- 
rally speaking,  the  most  marked  alteration  occurs  in  the 
fibres  composing  the  outer  line  of  Baillarger,  next  in  the 
super-  and  inter-radial  bundles,  whilst  the  superficial  tangential 


Pathology 

fibres  are  somewiiat  less  affected  (see  Fig.  9,  p.  63).  The  regions 
of  the  brain  most  involved  are  the  frontal  and  parieta.1  lobes  ;  in 
the  motor  areas  the  change  is  comparatively  slight,  and  in  the 
occipital  lobes  there  is  often  little  observable  diminution. 

The  Neuroglia. — Sclerosis,  or  overgrowth  of  neuroglia,  occurs 
in  some  form  or  other  in  a  considerable  proportion  of  cases. 
Dr.  Wilmarth*  found  it  in  no  less  than  one  quarter  of  the  hundred 
brains  he  examined.  The  cause  of  this  condition  cannot  always 
be  determined ;  in  some  cases  it  would  appear  to  be  a  develop- 
mental  anomaly,  and  to  take  place  in  consequence  of  the  dimin- 
ished multiplication  and  development  of  the  higher  elements — 
the  nerve  cells.  In  such  cases  it  is  probably  of  a  diffuse  nature. 
In  a  brain  of  this  kind  which  I  examined  from  an  idiot  dying  at 
the  age  of  twenty  years,  the  whole  organ  was  small,  896  grammes 
in  weight,  and  exceedingly  firm — in  fact,  almost  cartilaginous 
in  texture  throughout.  There  were  no  localized  patches,  but 
microscopical  examination  showed  the  presence  of  a  dense 
overgrowth  of  neuroglia  diffused  throughout  all  parts  of  the 
brain,  including  the  basal  ganglia  and  cerebellum.  This  in- 
volved the  white  as  well  as  the  grey  matter,  and  was  accom- 
panied by  a  marked  numerical  diminution  as  well  as  irreguJar 
and  incomplete  development  of  the  nerve  cells  and  their  processes. 
There  were  no  signs  of  recent  degeneration,  but  the  pia-arachnoid 
membrane  was  somewhat  thickened  in  places.  The  patient  had 
always  been  helpless  and  unable  to  do  anything  for  herself,  but 
no  definite  paralysis  was  noticeable.  She  was  subject  to  constant 
choreiform  movements,  but  there  were  no  convulsions. 

In  the  majority  of  cases,  however,  the  overgrowth  of  neuroglia 
occurs  in  the  form  of  localized  patches.  These  are  found 
in  three  chief  situations,  although  all  may  be  involved  in 
a  single  case.  The  commonest  site  is  the  grey  matter  of  the 
cerebral  cortex,  which  may  be  occupied  by  a  large  number  of 
sharply  circumscribed  sclerotic  areas  varying  in  size  from  a  pin- 
head  to  a  hazel-nut,  or  even  larger.  As  generally  seen,  these  are 
pale  firm  masses  which  project  above  the  level  of  the  affected 
hemisphere,  they  are  often  marked  by  a  central  umbilication, 
and  the  investing  pia  membrane  strips  from  them  with  unusual 

*  A.  W.  Wilmarth,  "  Report  on  the  Examination  of  One  Hundred 
Brains  of  Feeble-Minded  Children,"  Alienist  and  Neurologist,  October,  1890. 


6o  Mental  Deficiency 

readiness  and  without  causing  decortication.  This  condition 
was  first  described  by  Bourneville,*  but  many  examples  have 
since  been  recorded  under  the  name  of  hypertrophic,  nodular, 
or  tuberous  sclerosis  or  gliosis.  The  majority  of  the  patients 
have  been  markedly  mentally  deficient  and  have  suffered  from 
•^l?Hti!9--£^^^^^^^^^^^^^^^-  T^^  patches  consist  of  a  dense  interlace- 
ment of  neuroglia  fibres  with  a  varying  proportion  of  cells 
(probably  dependent  upon  their  age),  and  the  lamination  of  the 
adjoining  grey  matter  is  often  considerably  distorted.  The 
next  most  common  site  is  the  floor  of  the  lateral  ventricles,  which 
may  be  studded  with  a  number  of  protuberances  the  size  of  small 
peas.  Microscopical  examination  shows  these  to  consist  of 
almost  pure  glia  tissue,  the  fibres  of  which  are  usually  arranged 
in  whorls  around  the  centre  of  the  nodule.  Finally,  a  dense 
band  of  fibrous  neuroglia  is  occasionally  seen  immediately 
under  the  pia  upon  the  surface  of  the  hemisphere,  closely  applied 
to  the  cortex  like  a  cap. 

When  neuroglial  overgrowth  is  present  to  any  considerable 
extent,  it  produces  a  marked  increase  in  the  weight  and  consist- 
ence, and  often  in  the  size,  of  the  brain.     With  the  lapse  of 

r^  time  it  tends  to  contract,  and  the  relative  age  of  the  cortical 
protuberances  may  be  gauged  by  the  size  and  depth  of  their  central 
umbilication.  It  is  probably  an  early  stage  of  extensive  neuro- 
gliosis  which  gives  rise  to  the  cranial  enlargement  in  the  hyperz, 

^  trophic  form  of  amentia,  and  this  condition  is  not  infrequently 
called  "  hypertrophy  of  the  brain."  The  hypertrophy,  however, 
concerns  the  supporting,  and  not  the  true  nervous  tissue. 

Regarding  the  manner  of  production  of  localized  sclerosis  there 
is  much  diversity  of  opinion,  although  the  lesions  suggest  some 
kind  of  vasi:ular  causaiLoii.  Jendrassik  and  Marie  point  oit  that 
the  first  histological  change  always  takes  place  around  the  small 
cortical  arteries,  and  in  a  case  of  Freud's  a  sclerotic  patch  was 
considered  to  be  undoubtedly  the  result  of  an  embolus  of  a  brancli 
of  the  middle  cerebral  artery./  Striimpell  sees  in  it  a  possible 
after-effect  of  his  polio-encephalitis  acuta  infantum.     Moreover, 

*  Bourneville,  "  Recherches  sur  I'ldiotie,"  etc.,  Paris,  1893  ."  see  also 
Joseph  Sailer,  "  Hypertrophic  Nodular  Gliosis,"  Journal  of  Nervous  and' 
Mental  Disease,  1898,  p.  402,  in  which  an  account  is  given  of  previously^ 
recorded  cases  ;  also  Freud,  "  Infantile  Cerebral  Lahmung,"  p.  136. 


Pathology  6 1 

the  view  of  Yascular  origin  derives  considerable  support  from 
the  fact  that  in  some  cases  the  lesions  are  strictly  confined  to 
one  hemisphere.  It  is  therefore  not  improbable  that  a  consider- 
able number,  at  all  events,  of  these  cases  of  tuberous  sclerosis 
have  their,  origin  in  one  or  other  of  the  vascular  cerebral  lesions 
occurring  before  birth  or  in  early  infancy,  in  some  cases  being 
caused  by  occlusions,  in  others  by  the  dissemination  of  a  poison. 
But  such  a  result  is  by  no  means  invariable  in  these  cases,  and  as 
to  why  the  result  should  in  some  be  sclerosis,  in  others  soften- 
ing with  cystic  formation,  or  in  others  chronic  meningo-encephal- 
itis  with  neither,  we  at  present  know  nothing.  The  nerve  cells 
are  in  many  cases  entirely  absent  from  these  patches  ;  it  is  by 
some  observers  contended  that  they  have  been  strangled  by  the 
neuroglia.  It  may  be,  however,  that  the  neurogliosis  is  but  a 
consequence,  and  not  a  cause,  of  their  death.  Where  nerve  cells 
occur  they  are  rarely  healthy,  some  being  in  a  state  of  imperfect 
development,  whilst  others  are  atrophied  and  distorted  (see 
Plate  I.,  Fig.  5).  The  contiguous  portion  of  the  cortex  is  usually 
very  irregular.  The  nerve  fibres  rarely  show  any  acute  degenera- 
tion, although  the  tangential  and  association  pathways  of  the 
brain  and  the  efferent  tracts  of  the  cord  are  often  considerably 
diminished  in  size.  The  endothelial  cells  of  the  capillaries  fre- 
quently contain  black  fatty  granules,  and  in  some  of  the  sclerotic 
areas  indications  of  old  haemorrhage  exist  in  the  presence  of 
haematoidin  crystals. 

Bloodvessels. — As  a  rule  the  bloodvessels  of  the  brain  show 
little  or  no  departure  from  the  normal.  Occasionally  hyaline 
degeneration  is  present  ;  or  there  is  a  collection  of  pigment, 
similar  to  that  in  the  nerve  cells,  disposed  around  the  nuclei  of 
the  capillary  endothelium.  These  conditions  are  not  constant, 
and  I  do  not  think  they  have  any  causal  relationship  to  the 
amentia. 

Situation  of  the  Cellular  Changes. — With  regard  to  the  laj^ers 
in  which  these  imperfections  are  most  evident,  it  was  stated  by 
Bevan  Lewis  that  embryonic  cells  were  particularly  numerous 
in  the  semmj  and  tiTvrdj^ortical  layers  (the_small  and  medium 
pyramids),  and  my  own  observations ^re  entirely  in  agreement 
with  this.  Incompletely  developed  cells  occur,  it  is  true,  in  all 
the  cortical  layers,  and  in  extreme  cases  of  idiocy  they  may 


62  Mental  Deficiency 

even  be  seen  in  the  spinal  cord  ;   but  it  is  in  the small  and_ 

QlM^le^^yramMj-L  ceHs  tha^^^^  greatest  change  is  evident.  In 
view  of  the  fact  that  these  cells  are  normally  amongst  the  last 
tjo  attain  their  full  development,  also  that  they  are  the  earliest 
,  and  most  affected  in  dementia  resulting  from  epilepsy  and 
chronic  insanity,  this  fact  is  of  considerable  interest. 

In  cases  of  pronounced  amentia  these  incompletely  developed 
pyramidal  cells  are  found  in  all  regions  of  the  cerebral  cortex. 
There  are,  however,  two  situations  in  which  they  are  most 
frequent,  namely,  the  p^^frontal  and,  to  somewhat  less  extent, 
the  parietal  lobes.  It  would  therefore  appear  that  it  is  these 
regions  which  are  chiefly  concerned  in  the  highest  mental  pro- 
cesses, for  it  is  these  same  regions  which  show  the  greatest 
amount  of  degeneration  in  dementia.  On  this  point  the  observa- 
tions of  J.  S.  Bolton,*  whose  work  on  the  morbid  histology  of 
the  cortex  cerebri  is  probably  unsurpassed  for  painstaking  care 
and  completeness,  are  of  great  importance.  Bolton  concludes 
that  "  the  cellular^elements  throughout  the  cortex  cerebri  which 
are  specially  concerned  in  the  performance  of  associational 
functions  are  those  of  the  pyramidal  layer  of  nerve  cells  ;  the 
great  anterior  centre  of  association  of  Flechsig  in  the  prefrontal 
'fegion  is  under-developed  on  the  one  hand  in  all  grades  of 
primary  mental  deficiency,  and  on  the  other  hand  undergoes 
primary  atrophy  pari  passu  with  the  development  of  dementia/i 
This  region  of  the  cer^J^rum  is  therefore  concerned  with  the 
performance  of  .the  highest  co-ordinating  and  associational 
processes  of  mind." 

It  is  not  improbable  that  the  anatomical  basis  of  psychic 
epilepsy  and  insanity  will  ultimately  be  proved  to  consist  in  an 
'inherited  instability,  defective  metabolism,  or  tendency  to  pre- 
mature degeneration  of  these  cells,  the  actual  exciting  cause  of 
the  disease  being  supplied  by  any  of  the  numerous  forms  of 
stress  and  strain  incident  to  modern  life. 

In  concluding  this  account  of  the  histological  changes  in 
primary  amentia,  it  is  necessary  to  remark  that  embryonic  cells 
similar  to  those  described  (neuroblasts),  are  present  in  the 
normal  adult  brain,  also  that  cells  which  appear  to  be  of  perfect 

*   J.  S.  Bolton,  "Amentia  and  Dementia,"  Journal  of  Mental  Science 
April,  1905,  et  seq. 


Pathology 
Plate  II. 


63 


Fibres 


AMENTIA 


V  B 


DEMENTIA 


Cells 


y  D 


Fig.  9, — Microscopical  Sections  of  the  Frontal  Cortex  in  Dementia, 
Amentia,    and    the    Normal    Conditions    (Semi-Diagrammatic, 

DRAWN    BY    A.    F.    TrEDGOLD). 

On  the  left  of  each  are  shown  the  /Id res  as  they  appear  in  sections  stained  by  the  Marchi-Pal 
method,  on  the  right  the  cel/s  as  they  appear  in  Nissl  sections.  The  various  layers  are  as 
follows  : 

Fibres. — (i)  Tangential,  chiefly  formed  by  the  ramifications  of  the  collateral  processes  from 
cells  at  A,  B,  C,  and  Z>,  also  the  terminals  of  some  of  the  fibres  forming  the  medullary  rays. 
This  line  is  normally  well  defined;  in  amentia  it  is  somewhat  diminished,  in  dementia  markedly 
so.  (2)  iiuper-radial.  A  i^'M  horizontally-coursing  fibres  are  situated  here,  but  this  region  is 
chiefly  occupied  by  cells  {B).  (3)  Outer  line  of  Baillarger  (line  of  Vicq  d'Azyr),  horizontally- 
coursing  fibres  composed  of  collaterals  from  cells  at  B,  C,  and  A",  a  well-marked  line  normally, 
rnuch  diminished  in  amentia  and  dementia.  (4)  Inter-radial,  a  less  definite  bundle,  probably  of 
similar  constitution  to  (3),  diminished  in  amentia  and  dementia.  (5)  White  7)iatter  of  centrum 
ovale.  The  vertical  bundles  are  composed  of  axones  from  B,  C,  and  D,  and  of  medullated  fibres 
from  other  regions  of  the  brain. 

Celi.s. — {A)  Neuroglia  and  small  irregular  ner7<e-cell<.  {B)  Small  and  (C)  Medium 
pyramids.  In  amentia  there  are  comparatively  few  cells  in  these  layers,  and  those  present  are 
irregular  in  arrangement  and  of  incomplete  development  ;  in  dementia  many  of  these  cells  are  in 
an  advanced  state  of  degeneration.  (£?)  Large  pyramids,  similar  changes  to  those  in  the 
preceding  layers,  but  not  so  extensive.  {E)  Polymorphous  cells.  It  will  be  noticed  that  in 
amentia  the  whole  cortex  is  much  thinner  than  in  the  normal  condition.  This  is  principally  due 
to  the  defective  development  of  the  cells  at  B,  C,  and  D,  but  especially  to  those  at  B. 


64  Mental  Deficiency 

development  may  be  seen  in  the  brain  of  the  idiot,  even  of  the 
most  pronounced  type  ;  but  whereas  in  the, normal  the  number 
of  neuroblasts  is  comparatively  small,  and  the  great  majority  of 
the  cells  have  attained  complete  development,  in  the  latter  the 
reverse  is  the  case,  the  bulk  of  the  cells  being  in  an  immature 
condition,  and  many  of  them  also  showing  further  indications 
of  defective  function  in  the  presence  of  considerable  deposits 
of  pigment.  Moreover,  the  proportion  of  such  immature  cells 
appears  to  be  directly  related  to  the  de^ee  of  mental  deficiency, 
and  in. the  milder  degrees  the  microscopical  condition  is  rather 
one  of  paucity  of  cells  and  irregular  arrangement  than  of  pro- 
nounced imperfection  of  the  individual  cells. 


[istokfey 


The  HistokJgy  of  Secondary  Amentia. 

As  has  already  been  stated,  the  difference  between  primary 
and  secondary  amentia  is  that,  whereas  in  the  former  the  full 
development  of  the  neuroblasts  cannot  take  place  by  reason  of 
an  intrii^ic  vital  deficiency,  in  the  latter  their  development  is 
arrested   by   some   external   cause.     This    cause   may   operate 

■^generally,  as  in  cretinism,  or  its  effect  may  be  local,  as  in  acute 
polio-encephalitis  or  the  vascular  changes  occurring  in  birth 
injuries.  In  many  of  these  cases  the  nerve  cells  present  similar 
histological  features  to  those  in  the  primary  form,  although  it 
may  be  possible  to  infer  that  the  condition  is  secondary  from  the 
localized  nature  of  the  agenesis  and  the  presence  of  softening, 
sclerosis,  chronic  inflammation,  or  other  signs  of  disease  in  an 
otherwise  well-developed  brain. 

In  a  considerable  number  of  these  secondary  cases,  however, 
degeneration  of  nerve  cells  subsequently  takes  place,  this  being 
often   accompanied   by   more   or   less   dementia.     Where   this 

•  happens,  the  detection  of  incompletely  developed  cells  may  be 
.exceedingly  difficult,  just  as  the  original  amentia  may  be  un- 
recognizable in  th^  midst  of  the,  dementia.  Such  degeneration  is 
a  slow  and  chronic  process,  there  being  rarely  any  acute  change 
discoverable  by  Marchi's  method  of  staining.  It  begins  as  a 
chromatolysis,  with  accumulation  of  brownish-yellow  granular 
pigment  ;  this  is  followed  by  a  gradual  atrophy  of  the  axon  and 

^dendrons,  and  then  by  a  shrinkage  of  the  cell  body.     Later  dis- 


Pathology  65 

integration  of  the  nucleus  and  nucleolus  occur,  and  this  is  often 
followed  by  sclerosis.  - 

The  cerebral  vessels  sometimes  show  indication  of  this  chronic 
degeneration  in  a  thickening  of  their  walls  ;  whilst  the  endothelial 
cells  of  the  capillaries  and  the  adventitia  of  the  smaller  arteries 
frequently  contain  a  considerable  deposit  of  brownish-yellow 
pigment  (staining  black  with  Marchi's  fluid)  similar  to  that  met 
with  in  the  nerve  cells. 


Morbid   Anatomy. 

Gross  Developmental  Anomalies  and  Pathological  Lesions. — 

Although  the  essential  pathological  condition  underlying  amentia 
is  one  of  imperfect  or  arrested  development  of  the  cortical  cells, 
yet  in  a  considerable  proportion  of  cases  anomalies  of  structure 
occur  which  are  sufficiently  gross  to  be  recognizable  by  the  naked 
eye.  These  fall  under  two  headings,  viz.  :  (i)  Faults  of  develop-' 
ment,  and  (2)  Lesions  resulting  from  disease.  The  former  occur 
in  cases  of  primary  amentia  only,  and  they  are  obviously  a  more 
gross  manifestation  of  that  same  germinal  blight  which  has 
produced  the  cellular  imperfection.  The  latter  are  the  after- 
effects of  pathological  processes  which  on  the  one  hand  produce 
secondary  amentia,  and  on  the  other  may  complicate  primary 
amentia.  The  following  are  the  chief  of  these  developmental 
anomalies  and  lesions  : 

The  brain  of  many  mild  aments,  in  its  size,  weight,  and  general 
appearance,  may  not  be  markedly  different  from  the  normal, 
but  in  the  more  pronounced  degrees  of  mental  deficiency  differ- 
ences are  usually  obvious.  I  have  never  yet  seen  the  brain  of 
an  idiot,  a  low  or  even  medium  grade  imbecile,  which  could  be 
regarded  as  normal  upon  careful  naked-eye  examination.  Some- 
times it  is  too  large,  when  sections  will  show  that  it  contains 
an  excess  of  glia  ^tissue.  More  often,  however,  it  is  too 
small,  and  the  average  weight  of  the  encephalon  of  the  ament, 
even  excluding  cases  of  microcephaly,  is  several  hundred  grammes 
less  than  the  average  of  the  ordinary  population.  In  many 
instances  the  ^xture  is  either  abnormally  soft  or  unusually 
dense.  In  many  cases,  also,  there  is  either  a  decided  peculiarity 
in  the  whole  configuration,  or  the  convolutions  are  irregular 

5 


66  ^  Mental  Deficiency 

and  of  markedly  diminished  complexity.  In  addition  there  are 
often  gross  malformations  of  development.  In  cases  of  secondary 
amentia  these  changes  may  be  little  marked,  but  they  are 
generally  replaced  by  some  obvious  sign  of  disease. 

Malformations  of  the  central  nervous  system  vary  from  a 
trifling  peculiarity  of  configuration  or  anatomical  arrangement 
to  a  complete  suppression  of  important  structures,  such  as  is 
seen  in  anencephalia,  non-development  of  the  medulla,  or  even 
absence  of  the  spinal  cord.  Such  severe  conditions  as  these  are, 
of  course,  incompatible  with  life,  and  even  if  the  children  were 
•  born  alive,  they  could  only  survive  a  few  hours.  The  malforma- 
tions ordinarily  seen  in  post-mortem  examinations  of  aments  are 
much  less  severe,  and  are  in  most  instances  situate  in  the  cerebral 
hemispheres  or  the  cerebellum.  This  is  doubtless  owing,  as 
Ziegler  says,  to  the  fact  that  these  parts  "  in  their  development 
from  the  primary  cerebral  vesicles  undergo  the  greatest  amount 
of  growth  and  the  most  important  transformations." 

Most  of  these  anomalies  are  forms  of  localized  hypoplasia, 
which  in  some  instances  may  be  the  result  of  disease  or  vascular 
occlusion  ;  in  others,  however,  they  are  due  to  defects  in  the 
formative  material  of  the  brain.  In  the  cerebral  hemispheres 
the  secondary,  or  e.ven  the  primary,  fissures  may  be  imperfectly 
formed,  there  may  be  agenesis  of  a  lobule  or  a  whole  group  of 
convolutions,  or  there  may  be  a  general  undergrowth  of  the 
wjiple  of  one  hemisphere.  This  latter  condition  is  called  cerebral 
hemiatrophy,  and  the  affected  hemisphere  may  be  from  200  to 
300  grammes  weight  less  than  the  opposite  one.  In  a  consider- 
able proportion  of  cases  a  condition  of  microgyria  is  seen,  in  which 
a  group  of  contiguous  convolutions  are  represented  by  thin 
rnembranous  folds,  almost  devoid  of  nervous  tissue,  and  somewhat 
resembling  the  conduplication  seen  in  the  unexpanded  petals  of 
a  flower-bud.  Porencephaly*  is  another  not  uncommon  patho- 
logical finding,  and  is  due  to  a  non-development  of  the  central 
convolutions  around  the  inferior  extremity  of  the  Sylvian 
fissure.  As  a  consequence,  a  deep  funnel-shaped  cleft  is  pro- 
duced which  extends  down  to,  and  communicates  with,  the 
cavity  of  the  lateral  ventricle.     This  cleft  is  lined  by  the  pia  and 

*  See  Kundrat,  "Die  Porencephalie,"  Graz,  1882  ;    also  Audry,  "  Les 
Porencephalies,"  Revue  de  Midecine,  June,  1888. 


Pathology  67 

bridged  over  by  the  arachnoid  membrane,  the  contained  space 
being  filled  with  cerebro-spinal  fluid.  A  somewhat  similar 
depression  may  arise  as  the  result  of  disease  of  the  brain  matter 
external  to  the  lateral  ventricle,  which  in  many  instances  is 
brought  about  by  a  lesion  of  the  Sylvian  artery.  This  condition, 
as  well  as  other  circumscribed  and  cystic  depressions  of  the  brain 
surface,  or  even  severe  hemiatrophy,  are  often  described  as 
pseudo-porencephaly . 

Other  more  uncommon  developmental  anomalies  of  the 
encephalon  consist  of  malformations  of  the  basal  ganglia,  de- 
ficiency or  absence  of  the  corpus  callosum,  fornix,  optic  thalami, 
corpora  quadrigemina,  and  corpora  mammillaria.  Arndt  and 
Sklarek,  in  a  post-mortem  examination  on  an  imbecile  girl  aged 
sixteen  years  who  died  in  the  Dalldorf  Asylum,  found  that,  in 
addition  to  deficiency  of  the  corpus  callosum,  there  were  ab- 
normalities of  the  pillars  and  commissure  of  the  fornix,  of  the 
gyrus  fornicatus  and  fibres  of  the  anterior  commissure,  as  well  as 
absence  of  the  psalterium  and  septum  pellucidum.  They  quote 
twenty-nine  recorded  cases  of  deficiency  of  the  corpus  callosum, 
most  of  them  accompanied  by  other  defects  of  brain  structure, 
and  the  majority  of  the  patients  being  idiots. 

Anomalies  of  the  cerebellum  consist  chiefly  of  a  general  hypo- 
plasia, which  occurs  with  considerable  frequency  in  the  Mongo- 
lian type  of  amentia,  as  well  as  of  various  forms  of  localized 
agenesis  similar  to  those  met  with  in  the  cerebrum. 

It  is  to  be  remarked  that  such  lesions,  whether  due  to  faults 
of  development  or  to  disease,  are  very  likely  to  interfere  with 
the  growth,  or  to  cause  degeneration,  of  other  portions  of  the 
nervous  system  wdth  which  the  affected  areas  are  functionally 
related.  Thus,  in  lesions  of  the  motor  cortex  there  is  sclerosis 
of  the  corresponding  efferent  tract  throughout  the  pons,  medulla, 
and  cord,  and  corresponding  to  this  there  is  often  a  numerical 
diminution  of  the  anterior  horn  cells  of  the  cervical  and  lumbar 
enlargements.  Lesions  of  the  I^sal  ganglia-may  give  rise  to 
secondary  changes  in  the  cerebellum  and  its  superior  peduncle 
of  the  opposite  side,  also  in  the  fillet  and  interolivary  layer  of 
the  pons  and  medulla  of  the  same  side.  Lesions  of  the  nioto*- — 
^coxtex  may  even  interfere  with  the  development  of  the  great 
association  centres.      In  examining  anomalies   of  the  nervous 

5—2 


68  Mental  Deficiency 

system,  it  is  thus  not  always  easy  to  disentangle  those  lesions 
which  are  primary  from  those  which  are  in  this  way  secondarily 
produced. 

Hydrocephalus  is  a  not  uncommon  accompaniment  of  both 
the  primary  and^  secondary  forms  of  amentia ;  it  occurs  in  two 
varieties.  In  one  variety  the  excess  of  cerebro-spinal  fluid  occurs 
within  the  ventricles,  and  is  then  known  as  '' internal  hydro-^ 
cephalus."  In  the  other  it  is  situated  external  to  the  surface 
of  the  brain,  and  is  then  known  as  "  meningeal  hydrocephalus  " 
or  '*  hydrocephalus  ex  vacuo.'' 
C-  The  cause  of  Internal  Hydrocephalus  is  often  obscure.  Some 
cases  date  from  early  embryonic  life  ;  in  others  the  condition 
first  appears  in  early  childhood.  Both  syphilitic  and  tuber- 
cular lesions  have  been  found,  and  in  other  cases  chronic 
thickenings  of  the  choroid  plexuses  are  seen.  It  is  probable 
that  the  affection  in  many  instances  depends  on  closure  of 
the  communications  between  the  cavities  of  the  ventricles 
and  the  subarachnoid  spaces  in  the  transverse  fissure  ;  but 
as  to  the  causes  bniyi||g  about  this  closure  we  know  very 
little.      On  the  o^^^nSId,   there  is  no  doubt  that  in  some 


ai^vdrocej 


instances  internar^nydrocephalus  may  be  secondary  and  com- 
pensatory to  non-development  of  the  brain  tissue.  This  is 
probably  so  in  those  cases  where  it  is  confined  to  one  ventricle, 
the  substance  of  the  corresponding  hemisphere  being  thin  and 
undeveloped  ;  also  in  those  cases  in  which  it  accompanies  a 
general  hypoplasia  of  the  cerebrum,  such  as  occurs  in  micro- 
cephaly. Distension  of  the  ventricles,  even  to  a  considerable 
extent,  is  a  not  very  uncommon  finding  in  microcephalic  amentia. 

Ir  External  Hydrocephalus  is  always  compensatory  to  disease  or 
non-development  of  the  cerebral  tissue.  The  excess  of  fluid  is 
situate  in  the  subarachnoid  space,  and  always  occurs  in  the 
vicinity  of  the  local  defects.  In  cases  of  general  atrophy  of 
the  convolutions  due  to  dementia,  the  dilated  sulci  are  filled 
with  pale,  clear  cerebro-spinal  fluid.  In  conditions  of  localized 
disease,  or  agenesis,  on  the  other  hand,  the  fluid  is  confined  to 
form  a  cyst.  This  is  particularly  well  seen  in  some  cases  of 
-pseudo-porencephaly.     It  may  happen  for  internal  and  external 

r     ]wdrocephalus  to  be  present  in  the  same  brain. 

I  Encephalitis  and  Meninso-Ence^phalitis. — These  conditions  are 


Pathology  69 

always  indicative   of   a   previous   disease  of  the  brain.     They 
are  therefore  commoner  in,  but  not  restricted  to,  the  secondary__ 
Jaon  -of  amentia.     The  cause  is  one  or  other  of  the  toxic  or 
vascular  lesions  which  have  already  been  described  in  the  chapter 
on  Causation  ;  but  they  have  no  constant  relationship  to  any 
particular  one  of  them.      Encephalitis  may  result   alike   from 
cortical  haemorrhages,   thrombosis  of  the  meningeal  veins  due 
to  asphyxia,  or  a  poisoning  of  the  cortical  cells.     Sachs*  con- 
siders chronic  meningo-encephalitis  to  be  a  common  result  of  A     / 
the  meningeal  haemorrhages  occurring  during  birth,  but  Freud   j  / 
is  of  opinion  that  these  cases  do  not  commonly  terminate  in  a/^ 
chronic  inflammatory  process  between  the  membrane  and  under/ 
lying  brain  surface.  y/ 

There  can  be  no  doubt  that  in  the  majority  of  cases  of  amentia 
which  are  due  to,  or  accompanied  by,  "  birth  paralysis  "  (Little's 
disease),  meningeal  haemorrhage  is  present,  although  in  occa- 
sional instances  the  haemorrhage  may  be  within  the  brain  cortex. 
Where  the  bleeding  is  from  the  membrane,  the  clot  is  usually  ^ 
between  the  pia  and  the  brain  surface,  and  it  may  be  situated 
over  the  vertex  or  at  the  base.  HoJ^pifcfc^that  the  posterior 
part  of  the  base  is  much  the  more  f requent^Hf  and  that  a  diffuse 
haemorrhage  is  commoner  than  is  a  single  circumscribed  clot. 
He  further  states  that,  whilst  the  quantity  of  blood  extravasated 
varies  from  one  drachm  to  four  ounces,  it  is  usually  about 
one  ounce. 

However  produced,  inflammation  of  the  cerebral  cortex 
usually  leads  to  marked  histological  changes.  In  most  cases 
there  is  considerable  distortion  of  all  the  affected  tissue,  so  that 
the  lamination  is  exceedingly  confused  and  irregular.  In  many 
cases  the  normal  layers  are  almost  indistinguishable,  and  the 
cortex  consists  of  a  haphazard  collection  of  various-sized  cells. 
Associated  with  this  there  may  be  a  clear,  pale  layer  devoid  of 
cells  at  a  little  distance  below  the  brain  surface.  In  some  cases 
areas  of  sclerosis  are  found,  or  there  is  a  more  diffuse  pro- 
liferation of  the  neuroglia ;  in  other  cases  there  are  small 
localized  softenings.     The  vessels  are  often  numerous  and  the 

*  Sachs,   "A  Treatise   on   the  Nervous   Diseases   of    Children,"    New 
York.  1895. 
L        t  ^'  Holt,  "  Diseases  of  Infancy." 


70  Mental  Deficiency 

perivascular  spaces  dilated;  whilst  if  the  lesion  occurs  in  the. 
inotpx.,region,  there  is  usually  a  chronic  degeneration  of  the 
efferent  tract,  which  may  be  traced  through  the  medulla  and 
cord.  The  term  "agenesis  corticalis "  has  been  applied  by 
Sachs  to  this  condition  where  of  intra -uterine  origin. 

In  ^neningo-encephahtis.-  the  pia-arachnoid  is  found  to  be 
considerably  thickened,  opaque,  unduly  vascular,  and  firmly 
adherent  to  the  underlying  brain  tissue,  from  which  it  cannot 
be  detached  without  causing  decortication.  In  some  cases 
the  softening  and  disintegration  of  the  brain  substance  is 
definitely  circumscribed ;  the  space  thus  formed  is  filled  with 
cerebro-spinal  fluid,  and  bridged  over  by  the  investing  membrane, 
forming  a  so-called  arachnoid  cyst. 

In  a  certain  number  of  cases  of  amentia,  even  where  there  are 
none  of  these  gross  lesions,  dementia  supervenes.  There  is  then 
.  usually  found  more  or  less  atrophy  of  the  convolutions,  with  con- 
siderable excess  of  fluid  in  the  widened  sulci,  and  in  these  cases  the 
membranes  are  also  thickened  and  opaque  ;  but  the  pia-arachnoid 
strips  with  unusual  readiness,  unlike  the.  adhesion  in  chronic 
meningo-encephalitis.  The  dura-mater  is  sometimes  firmly 
attached  to  the  bone,  and  very  occasionally  osseous  plates  and 
subdural  false  membranes  have  been  found.  Apart  from  these 
conditions  of  disease  or  dementia,  the  membranes  in  persons 
y  suffering  from  amentia  rarely  show  any  pathological  change. 

The  Skull. — In  most  cases  of  primary  amentia  the  skull  is 
^-thicker  and  denser  than  normal,  the  diploe  often  being  non- 
existent. In  some  instances  the  sutures  are  found  firmly  and 
prematurely  united,  from  which  arose  the  erroneous  notion  that 
premature  synostosis  was  a  cause  of  idiocy.  Where  extensive 
cerebral  hemiatrophy  exists,  whether  from  disease  or  congenital 
anomaly  of  development,  there  may  be  considerable  asymmetry 
oLlhe  cmnium  as  seen  from  the  outside  ;  but  it  often  enough 
happens  that  jod.  external  malformation  is  noticeable  in  this  con- 
dition, the  deficiency  being  associated  with  a  considerable  enlarge- 
ment of  the  inner  table  of  the  skull  only.  In  some  of  these 
cases  there  is  no  bony  overgrowth  at  all,  the  space  being  merely 
filled  with  an  ^excess  ,ol„cer^bro-spinal  fluid.  The  various 
anomalies  of  external  configuration  will  be  described  in  sub- 
sequent chapters. 


CHAPTER  V 

CLASSIFICATION 

We  have  seen  that  there  are  two  fundamentally  different  forms  of 
amentia ;  there  are  also  innumerable  degrees ;  and  it  is  convenient 
to  describe  certain  distinctive  clinical  types.  Unfortunately,  the 
neglect  of  some  authors  to  make  these  distinctions  clear  has  had 
the  effect  of  unnecessarily  complicating  the  classification  of  mental 
deficiency,  which  is  in  any  case  a  task  of  sufficient  difficulty. 

The  Forms  of  Amentia. 

The  great  majority  of  aments  (probably  about  90  per  cent.) 
are  the  result  of  inherent  defects  of  the  germinal  plasm — morbid 
heredity.  In  consequence  of  this  blight,  neuronic  development 
is  irregular  and  faulty,  and  a  condition  of  primary  amentia 
ensues. 

In  about  10  per  cent,  of  cases  there  is  no  morbid  heredity  and 
no  inherent  inability  to  develop,  but  the  growth  of  some  portion, 
or  the  whole,  of  the  brain  is  interfered  with,  or  arrested  by, 
disease  or  other  adverse  environment.  This  condition  may  be 
called  secondary  amentia. 

At  first  sight  these  terms  may  appear  to  be  synonymous  with 
the  older  ones — "  congenital  "  and  "  acquired."  They  are  not 
so,  however,  for  so-called  ''  congenital  "  amentia  may  in  reality 
be  secondary  and  due  to  a  factor  of  the  environment  operating 
in  utero  ;  whilst  what  would  be  called  "  acquired  "  amentia 
may  really  be  the  result  of  a  primary  imperfection  which  has 
been  made  manifest  through  the  contributory  influence  of  some 
external  factor.  I  think,  therefore,  that  the  terms ' '  primary  "  and 
*'  secondary  "  are  not  only  more  accurate,  but  materially  assist  our 
conception  of  the  real  nature  of  the  condition  present.     As  will 

71 


72  Mental   Deficiency 

presently  be  seen,  these  two  forms  are  not  only  essentially  different 
in  their  etiology,  but  they  often  present  totally  distinct  patho- 
logical, psychological,  and  physiognomical  features. 

But  whilst  the  majority  of  cases  of  amentia  are  readily  referable 
to  one  or  other  of  these  two  chief  forms,  there  are  a  few  which 
seem  to  be  intermediate  between  them.  In  theseanorhid  heredity 
is  present,  but  the  brothers  and  sisters  of  the  patient  are  seemingly 
healthy,  and  the  patient  himself  has  seemed  to  be  well  in  body 
and  mind  until  the  advent  of  some  illness,  ''  fright,"  or  "  fall," 
etc.,  in  the  early  months  or  years  of  life.  These  cases  have  been 
called  develop_mental.  and  the  term  is  in  some  respects  very 
convenient.  But  inquiries  usually  show  that  the  exciting  factor 
is  of  a  comparatively  trivial  nature,  quite  disproportionate  to 
the  mental  disability  which  follows,  and  such  as  would  be 
incapable  of  damaging  the  nervous  system  of  a  healthy  child. 
There  can  be  no  doubt,  therefore,  that  in  such  cases  the 
inherited  condition  of  the  nervous  system  is  a  factor  of  the 
utmost  moment,  and  perhaps  the  term  delayed  primary  amentia 
would  best  define  the  class. 


The  Clinical  Varieties  of  Amentia. 

In  addition  to  the  fundamentally  different  forms  just  de- 
scribed, persons  suffering  from  amentia  present  minor  differ- 
ences which  are  exceedingly  useful  as  a  means  of  dividing  them 
into  clinical  varieties.  It  is  here,  however,  that  much  confusion 
exists,  for  authors  are  by  no  means  agreed  as  to  the  particular 
characteristics  which  should  be  used.  Some  would  attempt 
to  divide  aments  according  to  the  particular  cause  at  work ; 
but  though  this  is  practicable  in  the  case  of  the  secondary 
form,  it  is  not  so  with  regard  to  the  primary.  All  these  latter 
are  the  result  of  a  germinal  blight,  and  the  effect  is  the  same 
whether  that  blight  is  caused  by  alcohol,  tubercle,  or  any  other 
condition.  Even  with  regard  to  the  secondary  group,  the 
pathological  condition  would  in  many  cases  appear  to  afford 
a  better  means  of  classification  than  would  the  cause. 

The  classification  suggested  by  Ireland*  is  decidedly  the  best 
hitherto  devised,  but,  as  that  distinguished  author  is  the  first 
*  W.  W.  Ireland,  "  Mental  Affections  of  ChHdren,"  1898. 


r 


Classification  73 

to  acknowledge,  it  is  by  no  means  perfect,  and  is,  in  reality, 
little  more  than  an  enumeration  of  the  chief  clinical  varieties. 
Whilst  still  making  use  of  most  of  Dr.  Ireland's  clinical  groups,  I 
believe  that  the  investigations  which  have  been  made  in  recent 
years  enable  us  now  to  arrange  these  groups  in  a  much  more 
systematic  manner,  and  this  I  attempted  to  do  in  a  table  pub- 
lished several  years  ago.  This  table,  in  an  improved  form,  is 
given  on  p.  "]"]. 

The  Clinical  Varieties  of  Primary  Amentia. 

The  majority  of  persons  suffering  from  primary  amentia 
present  no  special  distinguishing  features  other  than  the  ana-, 
tomical  and  physiological  anomalies  common  to  aments  in- 
general  ;  they  may  therefore  be  termed  simj)le  arnents,  and  they 
correspond  to  the  ''  genetous  "*  group  of  Ireland.  In  others, 
however,  the  imperfection  of  development,  for  some  reason  or 
other,  has  taken  a  particular  form,  and  thereby  produced  marked 
cranial  or  physiognomical  peculiarities  ;  since  these  are  often 
associated  with  special  mental  characteristics,  we  are  justified 
in  alluding  to  them  as  separate  varieties.  The  most  important 
of  these  are  the  Microcephalics  and  the  Mongolians. '\ 

In  a  not  inconsiderable  number  of  primary  aments  (particu- 
larly of  the  simple  variety)  there  exist  sjevere  gross  lesions.  In 
many  cases  these  are  only  revealed  after  death,  but  it  occasion- 
ally happens  that  they  are  so  pronounced  during  life  as  to  justify 
the  use  of  them  as  a  further  means  of  classification.  Accordingly, 
we  may  describe  sclerotic,^  porencephalic,  and  (occasionally) 
hydrocephalic  subvarieties  of  primary  amentia.  Epilepsy  and 
paralysis  are  such  oamraon  complications  of  all  these  cases  that 
their  presence  can  hardly  be  said  to  constitute  separate  varieties. 

The  Clinical  Varieties  of  Secondary  Amentia. 

I  Cases  of  secondary  amentia  are  divisible  into  two  main  classes, 
according  as  to  whether  the  deficiency  (i)  is  brought  about  by  a 

*  This  term  is  open  to  the  objection  that  all  primary  aments  may  in 
reality  be  called  "  genetous." 

■j-  Negroid,  Grecian,  Egyptian,  and  American  Indian  types  have  also  been 
described ;  but  as  these  are  rare,  and  their  characteristics  by  no  means 
definite,  they  will  not  be  alluded  to  further. 


74  Mental  Deficiency 

general  or  localized  disease  of  the  brain  cells,  or  (2)  i^^duejo  some 
jexternal  factor  influencing  their  nutrition.  "" 

Class  I.  Amentia  due  to  Cerebral  Disease. — Diseases  of  the 
brain  may,  for  our  present  purpose,  be  divided  into  two  groups — 
first,  epileps.y,  secondly,  gross  lesions.  These  latter  may  arise 
from  many  different  causes  which  have  already  been  specified, 
and  the  lesions  themselves  present  different  anatomical  features. 
As  a  consequence  there  are  produced  more  or  less  well-marked 
clinical  varieties.     These  varieties  may  be  classified  as  follows  : 

1.  Epileptic  and  eclampsic  amentia. 

2.  Vascular,    toxic,    and    inflammatory    amentia,    including 

certain  special  clinical  types — i.e., 

porencephalic. 

Sclerotic. 

Hydrocephalic. 

3.  Syphilitic  amentia. 

4.  Infantile  cerebral  degeneration. 

Class  2.  Amentia  due  to  Defective  Cerebral  Nutrition, — The 
nutrition  of  the  brain  may  suffer  (i)  in  consequence  of  qualita- 
^tive  or  quantitative  anomalies  of  the  blood-supply,  or  (2)  as  a 
result  of  the  deprivation  of  nervous  stimuli  from  without. 
j^retinism  is  the  best-known  and  most  important  example  of  the 
former,  although  possibly  other  abnormal  states  of  the  blood 
may  so  act.  The  absence  of  the  necessary  nervous  stimuli  to 
development  produces  amentia  from  isolation  or  sense  depriva- 
tion. The  clinical  varieties  of  this  class  are  therefore  enumerated 
as — 

1.  Cretinism. 

2.  Amentia  due  to  defects  of  nutrition^ 

3.  Amentia  due  to  isolation  or  sense  de^rijiatum^ 

The  Degrees  of  Amentia. 

Amentia  varies  greatly  in  its  degree,  irrespective  of  form  or 
clinical  variety.  In  some  cases  the  defect  is  but  slight ;  in 
others  it  is  so  severe  that  mind  can  hardly  be  said  to  be  present 
at  all.  Between  these  two  extremes  there  is  every  gradation ; 
and  since  the  differences  are  of  quantity  rather  than  quality,  of 
degree  and  not  kind,  any  classification  must  be  an  arbitrary  one. 


Classification  75 

Esquirol  suggested  the  faculty  of  speech  as  a  dividing  hne  ;  but 
this  is  unsatisfactory,  as  there  are  quite  mild  aments  who  cannot 
speak.  Sollier*  proposed  the  faculty  of  attention  ;  but  this  is 
also  far  from  being  a  reliable  criterion  as  to  the  amount  of  defect. 
In  fact,  there  is  no  one  faculty  or  function  upon  the  presence  or 
absence  of  which  we  can  rely  as  a  means  of  defining  the  degree  of 
amentia. 

Nevertheless,  it  is  essential,  both  for  purposes  of  description 
and  administration,  that  a  division  should  be  made,  and  this,  on 
the  whole,  is  best  done  by  means  of  three  terms  which  have  long 
been  in  use — namely,  Feeble-mindedness,  Imbecility,  and  Idiocy. 
To  one  or  other  of  these  degrees  we  may  relegate  all  aments, 
although  it  is  to  be  remembered  that  the  boundary  lines  are  by 
no  means  distinct,  and  that  the  one  gradually  merges  into  the 
other.  We  may,  indeed,  if  necessary,  further  subdivide  each  of 
them  into  three  others,  and  thus  describe  high-,  medium-,  and 
low-grade  idiocy,  imbecility,  and  feeble-mindedness  respectively. 

A  concise  definition  of  these  three  terms  is  impossible,  for  the 
reason  that  they  are  used  with  reference  to  the  amount  of  general 
intellectual  capacity  present  ;  but  the  chief  characteristics  of  each 
are  summarized  in  the  following  descriptions.  A  definition  of 
amentia  has  already  been  given  on  p.  2. 

Feeble-Mindedness  (High-Grade  Amentia). — This  is  the  mildest 
degree  of  mental  defect,  and  the  feeble-minded  person  is  "  one 
who  is  capable  of  earning  a  living  under  favourable  circumstances, 
but  is  incapable,  from  mental  defect  existing  from  birth,  or  from 
an  early  age,  [a)  of  competing  on  equal  terms  with  his  normal 
fellows  ;  or  (b)  of  managing  himself  and  his  affairs  with  ordinary 
prudence.' '•\ 

Feeble-minded  persons  under  the  age  of  sixteen  years  come 
within  the  jurisdiction  of  the  education  authority  by  reason  of  a 
special  Act  of  Parliament  (Defective  and  Epileptic  Children 
Act,  1899).  On  account  of  this  Act  they  are  commonly  desig- 
nated mentally  defective  children,  and  they  are  defined  as  "  those 
children  who,  not  being  imbecile,  and  not  being  merely  dull  and 

*  P.  Sollier,  "  Psychologie  de  I'ldiot  et  de  1' Imbecile,"  Paris,  1891. 

•j-  This  and  the  following  definitions  were  suggested  by  the  Royal  College 
of  Physicians  of  London,  and  adopted  by  the  Royal  Commission  on  the 
Feeble-iVIinded  as  the  basis  of  classification  in  their  inquiries. 


76  Mental  Deficiency 

backward,  are,  by  reason  of  mental  defect,  incapable  of  receiving 
proper  benefit  from  the  instruction  in  the  ordinary  public  elementary 
schools,  but  are  not  incapable  by  reason  of  such  defect  of  receivings 
benefit  in  such , special  classes  or  schools  as  are  in  this  Act  men- 
tioned.'' 

It  should  be  remarked  that  in  America  the  term  "  feeble- 
mindedness "  is  not  thus  used  specifically  of  the  mildest  degree 
of  amentia.  In  that  country  it  is  applied  generically  to  the 
whole  order  of  amentia,  thus  being  sxnpnymous  with  the  English 
term  "  mental  deficiency."  There  has  been  an  attempt  in  this 
country  also  to  include  all  grades  of  defect  in  this  euphemistic 
description,  and  to  call  the  mildest  degree  of  all  (the  feeble-minded) 
"  mental  defectives."  The  attempt  has  not  met  with  much  suc- 
cess, however,  and  since  "  feeble-mindedness  "  is  in  itself  a  more 
specific  term  than  is  "mental  defect,"  I  think  it  is  decidedly 
better  to  restrict  its  use  to  the  mildest  degree. 

Imbecility  (Medium-Grade  Amentia). — The  imbecile  is  defined 
as  "  one  who,  by  reason  of  mental  defect  existing  from  birth,  or  from 
an  early  age,  is  incapable  of  earning  his  own  living,  hut  is  capable 
^f .^M^i'^S ^^^^^^f  against  common  physical  dangers."* 

Idiocy  (Low-Grade  Amentia). — The  idiot  is  defined  as  "a 
person  so  deeply  defective  in  mind  from  birth,  or  from  an  early 
age,  that  he  is  .unable  to  guard  himself  against  common  physical 
dangers."* 

It  may  be  remarked  that  these  three  terms  are  occasionally 
used  of  varying  degrees  of  dementia.,  particularly  the  dotage  of 
old  age,  just  as  "  mental  deficiency  "  is  sometimes  used  generally 
for  that  condition.  The  practice,  however,  is  to  be  deprecated 
as  likely  to  lead  to  considerable  confusion. 

In  addition  to  the  above,  it  may  perhaps  be  well  in  this  place 
to  define  the  moral  imbecile  as  "  «  person  who  displays  from 
an  early  age,  and  in  spite  of  careful  upbringing,  strong  vicious  or 
criminal  propensities,  on  which  punishment  has  little  or  no  deterrent 
effect." 

*  See  note  p.  75. 


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CHAPTER  VI 

THE  PHYSICAL  CHARACTERISTICS  OF  AMENTIA 

We  have  seen  that,  in  an  overwhelming  proportion  of  persons 
suffering  from  amentia,  the  condition  is  the  result  of  a  blighted 
germinal  plasm.  The  effect  of  this  upon  development  will 
naturally  be  greatest  in  the  case  of  the  organ  of  most  delicate 
and  complicated  structure — namely,  the  n&rvous  system.  In 
mild  "cases  this  alone  may  be  involved,  and  it  may  even  happen 
that  the  injurious  effect  is  limited  to  the  least  organically  fixed 
structures  of  this  system — that  is,  to  the  neurones  subserving;  the 
highest  mental  processes.  ^ 

But  such  cases  are  relatively  few.  The  majority  of  aments  are 
the  product  of  a  markedly  abnormal  gerrmnal  plasm,  and,  as  a 
consequence,  not  only  the  brain,  but  the  whole  body  is  marred 
by  defects  of  anatomicardevelopment  and  physiological  function. 
Such  defects  are  known  as  stigmata  of  degeneracy. 

Stigmata  of  Degeneracy. 

In  recent  years  much  has  been  said  and  written  about  degene- 
racy, and  the  most  elaboratjfe,.tables  of  its  "  stigmata  "  have  been 
compiled.  These  have  been  divided  into  social,  psychological, 
physiological^ _.aimtomk^^^  groups,  and  some  writers 

would  seem  to  look  upon  any  departuretrom  their  conception 
of  what  is  or  should  be  the  normal  social,  psychological,  physio- 
logical, anatomical,  or  other  condition,  as  a  "  stigma  "  of  degene- 
racy. I  dojiot  think  this  view  is  justifiable.  In  the  firstj)lace, 
there  are  so  many  variations  within  healthy  limits' that  the 
"  normaP3^becomes  exceedingly  difficult  to  define.  Moreover, 
it  )5y^o  means  follows  that  a  condition  which  is  nnrnmm£)jx7or  - 
even  "  abnormal,"  is  on  that  account  a  mark  of  degeneracy,  or 


The  Physical  Characteristics  of  Amentia     79 

that  it  is  even  pathological  at  all.  We  have  not  yet  reached 
finality,  and  manners,  morals,  mind,  physiological  function,  even 
anatomical  structure,  are,  we  trust,  still  in  process  of  evolution  ; 
so  "'that  it  is  possible  for  some  of  these  anomalies  described.as 
''stigmata"  to  be  not  retrogressive,  but  actually  progressive. 

But  even  where  they  are  undoubtedly  pathological  or.  indica- 
tive of  a  diseased  condition,  it  does  not  follow  that  on  that 
account  they  are  stigmata  of  degeneracy.  As  has  already  been 
shown,  there  are  some  diseases  and  toxic  states  of  intra-  or  early 
extra-uterine  life  which  are  occasionally  capable  of  producing 
secondary  amentia,  and  in  these  cases,  although  the  germinal 
plasm  is  healthy,  there  may  nevertheless  be  produced  physio- 
logical and  anatomical  anomalies.  There  are  also  other  diseases, 
such  as  rickets  and  syphilis,  which  rarely  produce  mental  defi- 
ciency, and  yet  which  commonly  result  in  bodily  abnormalities. 
Even  in  cases  of  undoubted  degeneracy,  such  as  primary  amentia, 
some  of  the  bodily  conditions  which  are  commonly  called  "  stig- 
mata "  seem  to  me  to  be  not  a  concomitant  effect  of  the  germina 
imperfection,  but  the  result  of  the  imperfect  nervous  action. 
Lastly,  the  examination  of  perfectly  healthy  children  in  public 
elementary  schools,  as  well  as  of  ordinary  healthy  members  of 
the  general  population,  will  often  reveal  the  presence  of  so-called 
"  stigmata."  In  fact,  if  we  are  to  class  as  degenerates  all  persons 
coming  within  the  territory  defined  by  some  writers  on  this 
subject,  there  are  few  of  us  who  wdll  escape. 

I  am  far  from  denying  the  existence  of  degeneracy  and  its 
stigmata.  In  fact,  I  consider  primary  _amentia  itself  to  be  a 
true  degeneration,  and  many  of  the  anomalies  of  bodily  condi- 
tion present  in  these  persons  may  rightly  be  described  as  "  stig- 
mata "  of  degeneracy.  But  I  think  we  should  be  careful  to 
restrict  this  term  to  such  anomalies  as  are  really  manifestations^ 
of  this  state — that  is,  to  peculiarities  which  are  due  to  inherent" 
defects  of  the  germinal  plasm.  In  the  present  state  of  our  know- 
ledge this  differentiation  cannot  always  be  made.  Some — indeed, 
many — of  the  physical  characteristics  of  amentia  to  be  described 
are  certainly  the  result  of  degeneracy,  and  it  is  not  surprising 
that  such  should  be  numerous  and  severe  in  this  condition,  in 
the  lower  degrees  of  which  degeneracy  reaches  its  culminating 
manifestation.     But  some  of  these  characteristics  are  not  really 


8o  Mental  Deficiency 

degenerative.  I  shall  therefore  prefer  to  describe  them  all 
under  the  heading  of  "  Anomalies  of  Anatomical  Development 
and  of  Physiological  Function." 

It  has  been  remarked  that  similar  anomalies  occur  in  persons 
who  are  noToIherwise  abnormal.  IsTevertTieress,  it  is  abundantly 
clear  that  they  are  far  more  numerous  in  neuropaths  and  in 
aments  than  in  the  general  population.  Further,  that  their 
numh)er  and  severity  is,  on  the  whole,  directry_proportionate  to 
the  degree  of  defect.  Whilst,  therefore,  the  presence  of  a  single 
anomaly  has  little  or  no  diagnostic  importance,  the  presence  of 
two,  three,  or  more  is  of  considerable_significance  as  an  indication 
of  mental  defect. 

The  table  on  pp.  82-83  shows  the  various  anomalies  which  have 
been  noted  in  amentia  ;  the  chief  of  these  may  now  briefly  be 
described. 

Anomalies  of  Anatomical  Development. 

A.  Nervous  System. — These  have  already  been  described  in 
the  chapter  dealing  with  pathology. 

B.  Special  Sense  Organs. — Eai. — It  is  probable  that,  owing 
to  important  alterations  which  have  taken,  and  are  taking  place 
in  the  sense  of  hearing,  theexternal.  ear  is  at  present  in  a  state 
of  considerable  evolutionary  instability.  It  is,  therefore,  not 
surprising  to  find  that  anomalies  of  this  structure  occur  in  normal 
persons,  amongst  whom,  as  a  matter  of  fact,  they  are  extremely 
common.  This  being  the  case,  it  is  evident  that,  as  an  indica- 
tion of  degeneracy,  such  anomalies  are  in  themselves  of  little 
value,  and  I  must  dissent  from  the  dogmatic  utterances  of  some 
writers  that  a  certain  type  of  ear  can  be  labelled  "  criminal," 
another  *'  insane,"  and  so  on.  At  the  same  time,  there  is  no 
doubt  that,  frequent  as  are  such  departures  from  the  normal  in 
the  ordinary  population,  they  are  still  very  much  more  frequent 
in_d£generates ;,  and  when  they  occur  in  combination  with  two 
other  classes  of  defects — namely,  of  the  cranium  and  palate — I 
believe  that  they  have  considerable  diagnostic  value. 

With  regard  to  the  frequency  of  auricular  defects,  the  following 
figures  ascertained  by  Gradenigo,*  although  they  do  not  relate 

*  Gradenigo  {Arch,  de  Psychiatna,  1890  and  1892),  quoted  by  Talbot  in 
"  Degeneracy." 


The  Physical  Characteristics  of  Amentia     8i 

specifically  to  amentia,  are  of  considerable  interest.  As  the 
result  of  his  examination  of  several  thousands  of  persons  of  both 
sexes,  this  observer  found  that  the  external  ears  were  regular  and 
normal — 

In  56  per  cent,  of  males  and  66  per  cent,  of  females  of  the 
^  ordinary  population. 

In  36  per  cent,  of  males  and  46  per  cent,  of  females  of  the 

insane  population. 
In  28  per  cent,  of  males  and  54  per  cent,  of  females  of  the 
criminal  population. 

Also  that  in  the  insane  and  criminal  classes,  not  only  were  ear 
anomalies  more  frequent,  but  they  were  of  greater  gravity.  As 
tending  to  show  that  some  ear  anomalies  may  be  progressive 
rather  than  retrogressive,  it  may  be  stated  that  Talbot  found 
certain  varieties  were  more' frequent  in  ordinary  persons  than  in 
degenerates. 

The  varieties  of  malformation  of  this  structure  which  are  met 
with  in  persons  suffering  from  amentia  are  so  numerous  that  a 
detailed  account  of  them  all  is  impossible.  There  is  no  portion 
of  the  external  ear  which  may  not  be  affected,  but  the  following 
are  the  chief  conditions  met  with  :  Defects  of  the  lobule  are 
decidedly  the  most  frequent ;  it  is  often  unusually  large  and 
fleshy;  it  may,  however,  be  smaller  than  usual,  and  at  times 
even  absent ;  it  is  occasionally  adherent  to  the  face.  Another 
very  common  deformity  is  that  in  which  the  whole  ear  is  ex-/ 
cessively  large,  prominent,  and  outstanding,  with  a  marked 
convexity  as  seen  from  behind.  Another  common  type  is  the 
reverse  of  this,  the  entire  pinna  being  small,  thln7"and  circular, 
strongly  recalling  the  ear  of  the  chimpanzee.  With  or  without 
any  of  these  gross  changes  there  may  be  numerous  minor  mal-j 
formations  of  the  hehx  and  antihelix,  the  tragus  and  antitragus. 
Supernumerary  auricles  are  occasionally  present,  but  I  do  not 
think  that  anomalies  of  the  Darwinian  tubercle  are  more  frequent 
in  aments  than  in  the  normal  population.  It  occasionally 
happens  that  the  auditory  apparatus  is  so  imperfectly  developed 
that  total  or  severe  deafness  results.  This,  however,  is  un- 
common, and  deafness,  when  present,  is  usually  the  result  of 
disease,  especially  suppuration  of  the  middle  ear. 

6 


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84  Mental  Deficiency 

Eye. — Anomalies  of  the  eye  and  its  appendages  are  exceedingly 
common  in'^aments,  those  most  frequently  seen  being  the  fol- 
lowing :  Epicanthus-  a  ridge  of  skin  continued  from  the  upper 
eyelid  around  the  inner  canthus,  and  apparently  due  to  an 
unusual  redundancy  of  skin  in  this  region  ;  it  may  be  unilateral, 
but  usually  affects  both  eyes,  and  is  a  tolerably  frequent  anomaly 
in  aments,  although  not  unknown  in  normal  children.  Palpebral 
fissures,  which  are  small  and  obliquely  placed,  so  that'The  inner" 
is  lower  than  the  outer  end,  are  a  characteristic  feature  of  the 
Mongolian  variety  of  amentia.  Differently  coloured  and  speckled 
irides  are  very  common,  as  also  are  strabismus,  astigmatism, 
^hypermetropia,  and  less  frequently  myopia.  Corneal  opacities 
are  frequent,  but  colour-blindness  does  not  appear  to  be  more 
prevalent  than  in  the  ordinary  population. 

Nose. — A  clear-cut,  well-formed  nose  is  not  often  seen  in 
aments,  and  this  organ  is  usually  either  considerably  flattened 
or  depressed,  or  is  large  and  prominent,  with  wide  fleshy  nostrils 
which  look  forwards  rather  than  downwards.  Deviation  of  the 
septum  and  nasal  bones  may  also  occur. 

The  Lips  are  often  thick,  coarse,  prominent,  and  unequal  in  size. 
The  mouth  is  heavy  and  flabby-looking,  generally  open,  and 
devoid  of  either  refinement  or  firmness.     Hare-lip  is  not  common. 

The  Tongue  is  often  abnormally Jarge,  fissured,  and  its  papillae 
hypertrophied,  particularly  in  the  Mongolian  variety. 

C.  Osseous_  .System. — Abnormal  conditions  of  the  ..skeleton 
occur  with  extrerii£_irequency  in  amentia,  and  the  number  of 
these  persons  who  do  not  present  one  or  more  well-marked  bony 
anomalies  is  small.  The  cranium,  palate,  jaws,  and  teeth,  are 
the  parts  most  frequently  affected. 

Cranium. — Anomalies  of  the  cranial  vault  may  be  revealed  by 
inspection,  palpation,  and  mensuration  ;  also  by  tracings  from 
pliable  metal  bands  which  have  been  moulded  to  the  skull. 
Provided  this  latter  method  is  carefully  performed,  it  yields  very 
accurate  results,  and  Dr.  Lapage*  has  recorded  a  most  interesting 
series  of  observations  taken  in  this  way.  The  process,  however, 
is  somewhat  too  tedious  for  general  work,  and  I  think  that  for 
practical  purposes  mensuration  is  the  most  suitable.  The  fol- 
lowing are  the  measurements  I  have  been  in  the  habit  of  taking 

♦  C.  P.  Lapage,  "  Feeble-Mindedness  in  Children,"  Medical  Chronicle, 
1905. 


The   Physical   Characteristics  of  Amentia     85 

for  several  years  ;  they  have  the  advantage  of  being  easily  carried 
out  and  recorded. 

The  measuremejits..are  taken  from  the  upper  point  of  attach- 
ment of  the  auricular  pinna  to  the  lateral  aspeH'of  the  skulT. 
This  point  was  suggested  to  me  many  years  ago  by  Dr.  J.  *§. 
Bolton  as  being  readily  ascertainable  in  every  case,  and  subject 
to  little  individual  variation  ;  it  is  designated  ''  X.''  From  the 
fixed  point  ''  X  "  of  one  side  a  steel  tape-measure  is  passed  in 
various  directions  to  the  corresponding  point  on  the  opposite 
side — namely,  (a)  over  the  glabella,  (b)  over  the  greatest  frontal 
prominence,  (c)  vertically  upwards,  (d)  over  the  greatest  parietal 
prominence,  (e)  over  the  external  occipital  protuberance.  An 
additional  sagittal  measurement  is  taken  from  the  glabella  over 
the  cranial  vault  to  the  external  occipital  protuberance,  and,  if 
desired,  a  further  measurement  can  be  taken  with  the  calipers 
between  the  two  points  ''  X." 

These  measurements  are  conveniently  recorded  by  means  of  a 
diagram  like  the  following,  which  can  be  rapidly  drawn  as  occa- 
sion requires,  or  printed  in  one  corner  of  the  case-sheet  : 


Fig.  10. 

It  will  be  observed  that  the  measurement  XAX  plus  XEX  gives  the  cranial 
circumference,  XCX  its  vertical  perimeter,  and  XBX  and  XDX  the 
greatest  frontal  and  parietal  perimeters  respectively.  If  the  circumference 
be  multiplied  by  XBX  and  XDX,  a  figure  is  obtained  which  is  a  con- 
venient index  of  the  total  cerebral  capacity. 

The  general  conclusion  at  which  I  have  arrived,  as  the  result 
of  an  extensive  series  of  measurements  of  the  crania  of  normal, 
insane,  epileptic,  and  defective  persons,  is  that,  in  the  majority 
of  aments  there  are  marked  departures  from  the  normal ;  but 
that  there  is  no  particular  type  of  skull  wj;iich  is  characteristic 
ofmat  condition.  The  chief  anomalies  are  the  following : 
Circiiinfevejice  :  The  avprage  rronria]  circumference  of  the  male 
adult  is  22  inches,  and  of  j-h^  fprnaie^2i|^mches!  Occasionally 
tlie  skull  of  the  ament  exceeds  these  figures,  but  as  a  rule  it  is 


86  Mental  Deficiency 

decidedly  less,  and  in  cases  of  microcephaly  it  is  often  as  little 
as  15  inches.  There  is  often  a  diminution  of  the  frontal  and 
parietal  perimeters,'  whilst  a  subnormal  development  of  the 
occipital  portion  of  the  skull  is   exceedingly  common.     Sym- 


metry :  The  two  halves  of  the  normal  skulLjiot  infrequently 
differ  slightly  in  size,  but  this  condition  is  much  commoner  and 
"Tar  more  marked  in  aments.  Where  paralysis  has  existed  from 
an  early  age,  this  condition  is  very  frequent,  the  lessened  measure- 
/  ment  corresponding  to  the  area  of  brain  destroyed  or  arrested  in 
'  its  development,  but  asymmetry  of  the  cranium  is  often  observed 
in  the  absence  of  any  paralytic  signs.  Usually  the  left  half  is  the 
smaller.  Lapage  found  that  lateral  asymmetry  occurred  in  158 
cases  out  of  a  total  of  198,  the  left  half  being  the  smaller  in  122, 
and  the  right  in  36.  Cranial  bosses  are  frequently  present, 
probably  as  a  result  of  rickets,  ,the  most  common  situations  being 
the  ossific  centres  of  the  frontal  and  parietal  bones.  In  a  few 
cases  an  interf  rontal  ridge  is  seen.  Finally,  the  whole  conformation 
of  the  skull  may  be  abnormal,  as  is  seen  in  the  oxycephalic  type. 

Palate. — The  association  of  abnormahties  of  the  palate  with 

mental  deficiency  has  long  been  recognized,  and  there  is  no 
doubt  that  it  is  one  of  the  commonest  malformations  occurring 
tfLlliiS-CQndit io'n .  Many  years  ago  Langdon  Down*  drew  atten- 
tion  to"  the  subject,  and  more  recently  Cloustonf  has  recorded  a 
large  number  of  observations  which  show  conclusively  that, 
although  deformed  palates  occur  in  the  normal,  they  are  far 
and  away  more  frequent  in  neuropaths  and  the  mentally  defec- 
tive. He  states  that  deformed  palates  are  present  in  19  per 
cent,  of  the  ordinary  population,  33  per  cent,  of  the  insane,  55  per 
cent,  of  criminals,  but  in  no  less  than  61  per  cent,  of  idiots. 
B||tt^i^  who  has  made  a  most  exhaustive  study  of  this  ques- 
^il^|[^s  compiled  an  elaborate  classification  of  the  various 
anomalies,  found  palatal  deformities  present  in  no  less  than 
82  per  cent,  of  idiots. 

Without  going  into  ultra-refinements,  it  may  be  stated  that 
the  majority  of  the  anomgJ:ies„mjet..with.jnay  be  arranged  under 
two  headings  as  follows ; — ^ 

*  J.  Langdon  Down,  Transactions  of  the  Odontological  Society  of 
Great  Britain,  1871. 

t  T.  S.  Clouston,  "  Neuroses  of  Development,"  1891. 

J  Petersen  and  Church,  "  Nervous  and  Mental  Diseases,"  1904. 


The   Physical  Characteristics  of  Amentia     87 

1.  Saddle-  or  Keel-shaped  Palates. — In  this,  the  commonest 
type,  there  is  a  contraction  of  the  alveolar  arch  between  the" 
bicuspid  and  molar  teeth,  the  palate  at  the  same  time  extending 
upwards  to  a  considerable  distance,  at  the  expense  of  the  nasal 
cavity.  In  consequence  an  appearance  like  the  inside  of  a 
saddle  or  boat's  keel  is  produced.  It  is  sometimes  marked  by  a 
narrow  central  antero-posterior  furrow,  but  the  front  tejeth^  do^ 
not  usually  protrude  in  this  type  of  palate. 

2.  V-shaped  Palates. — These  are  not  so  frequent  as  the  former. 
and  are  produced  by  a  gradual  narrowing  of  the  dental  arch 
from  the  first  molars  to  the  central  incisors,  the  point  of  the 
V  being  thus  directed  forwards.  Palates  of  this  type  may  also 
be  higher  than  normal,  and  the  narrowing  of  the  fore-part  of  the 
arch  usually  causes  considerable  nve\Trowding  and  protrusion  of 
th^e  front  teeth. 

A  great  deal  of  discussion  has  raged  round  the  cause  and 
manner  of  production  of  these  anomalies.*  It  has  been  con- 
tended by  E.  S.  Talbot  that  they  only  appear  during  the  second 
dentition,  between  the  sixth  and  twelfth  years  ;  but  this  is 
denied  by  Clouston,  John  Thomson,  and  other  physicians  of 
great  experience,  and  I  have  certainly  seen  numerous  instances 
before  this  period.  I  think  there  can  be  little  doubt  that  most 
of  them  are  real  stigmata,  and  a  further  indication  of  those 
formative  defects  which  play  suc^'  a  prominent  part  in  the 
production  of  amentia.  At  the_same  time  it  is  to  be  remem- 
bered that  the  palate,  like  the  external  ear,  is  probaHy  under- 
goiiT'g  considerable  evolutionary  changes,  and  many  of  the  slighter 
anomalies  may  be  due  to  this  cause. 

^^Clejji^palale  appears  to  be  on  quite  a  different  footing,  and  it 
is  doubtful  if  this  condition  and  its  common  associate,  hare-lip, 
can  be  regarded  as  real  stigmata  of  degeneracy.  Ji_j^  bnt  rarely 
met  wit]j^j|;i^  aiv^^^^^,  Langdon  Down  linding  it  only  in  0"5  per 
cent.,  and  Ireland  in  i  per  cent.,  of  idiots;  whilst  Talbot t  ex- 
amined 1,977  feeble-minded  children  without  meeting  a  single 
instance.  These  proportions  do  not  differ  materially  from  the 
normal,  for  Grenzer  (quoted  by  Talbot)  found  9  cases  on 
examining  14,466  presumably  normal  children. 

*  See  the  chapter  on  "  Genetous  Idiocy  "  in  Ireland's  book. 
t   Talbot,   "  Degeneracy." 


88  Mental   Deficiency 

Jaws. — Many  aments  have  a  receding,  others  a  protruding, 
mandible,  the  former  being  very  common  in  microcephaHcs. 
Asymmetry  of  the  upper  or  lower  jaw  is  not  uncommon. 

Teeth. — Considering  the  frequent  occurrence  of  deformities  of 
the  palate,  it  is  not  surprisi.n£XQ-.fii>Alh.g^-^a:^Qffl-a-]igs  of  the  teeth 
are^very  common,  and  a  good  set  of  teeth  is  exceedingly  rare  in 
the  mentally  defective.  They  are  usually  late  to  appear,  rnal^ 
formed,  and  unhealthy  when  present,  and  prone  to  early  deca}' 
and  disappearance.  Where  a  V-shaped  palate  is  present,  the 
upper  incisors  and  canines  are  generally  huddled  together  and 
protruding,  at  times  to  such  an  extent  as  to  be  left  uncovered  by 
the  lip.  The  remaining  teeth  may  be  very  irregular  in  arrange- 
ment, and  there  are  often  large  gaps  between  them.  The  wisdom 
teeth  are  seldom  seen.  It  often  happens  that  the  teeth  erupt  at 
different  planes  of  the  alveolus,  and  I  have  occasionally  seen  a 
complete  double  row  of  incisors.  In  addition,  the  teeth  are  indi- 
vidually ill-formed,  often  honeycombed  or  marked  by  trans- 
verse striae^  very  unhealthy,  and  surrounded  by  a  foul  mass  of 
exudation. 

Other  defects  of  the  osseous  system  are  seen  in  the  presence 
of  talipes,  polydactylism,  syndactylism,  and  other  deformities 
of  lingers  and  toes.  The  arms  are  often  disproportionately  long. 
Very  exceptionally  a  condition  of  gigantism  is  present.  As  a 
rulCj  however,  the  stature  is  diminished,  and  the  average  height  of 
aments  is  several  inches  less  than  that  of  the  ordinary  population. 

D.  Muscular  and  Cutaneous  Systems. — Various  anomalies  of 
the  skeletal  muscles  have  been  found  upon  dfssection,  but  they 
are  hardly  of  sufficient  importance  to  merit  further  description. 
Abnormalities  of  the  skin  are  frequent,  and  consist  of  coarseness 
of  the  integument,  excessive  and  unpleasant  secretion,  webbing 
of  the  fingers,  moles,  and  naevi.  There  is  often  an  excessive 
development  of  hair  upon  parts  usually  hairless,  and  a  lack  or 
deficiency  upon  those  which  are  generally  covered,  particularly 
the  face  and  chin  iruxLalea... 

Adenoma  Sebaceum. — In  this  place  reference  may  be  made  to 
thispecuiiar  condition  of  the  skin  sometimes  seen  in  aments,  and 
with  exlreme  rarity  in  normal  individuals.  Adenoma  sebaceum 
is  a  papular  new  growth  which  is  confined  to  the  face,  and  is 
chiefly  seen  on  the  side  of  the  nose,  but  occasionally  on  the  fore- 


The  Physical  Characteristics  of  Amentia     89 

head  or  chin.  It  is  usually,  but  not  always,  symmetrical,  and  the 
lesions  are  often  numerous.  They  are  either  firmly  imbedded  in, 
oT project  from,  the  skin,  and  they  vary  in  size  from  a  pin-head 
to  a  small  pea.  They  are  of  a  whitish  or  yellowish  colour,  but 
sometimes  bright  red  owing  to  numerous  telangiectases.  The 
papules  are  made  up  of  an  overgrowth  of  sebaceous  glands  and 
capillary  vessels,  often  surmounted  by  a  thickened  corium.  In 
many  cases  they  are  present  at  birth,  but  in  others  they  do  noF 
appear  until  late  in  childhood  or  puberty. .  As  a  rule,  they  persist 
throughout  life,  but  occasionally  undergo  spontaneous  involu- 
tion with  scarring.* 

E.  Circulatory  and  Respiratory  Systems.  —  The  most  impor- 
tant anomalies  are  stenosis  of  the  pulmonary  artery  and  defects  of 
the  auricular  and  ventricular  septa.  The  heart  also  is  usually 
srna]]e_r  than  that  of  a  normal  person  of  corresponding  weigEt.' 

F.  Alimentary  System. — Numerous  anomalies  of  the  various 
organs  of  this  system  have  been  observed  upon  dissection. 
^Meckel's  diverticulum  is  not  very  rare,  and  Talbot  states  that  the 
appendix  is  best  developed  in  degenerates. 

G.  Urinary  and  Generative  Systems.  —  Lobulation  of  the 
kidneys  is  not  uncommon,  and  anomalies  of  the  genital  organs 
are  of  considerable  frequency.  These  consist,  in  the  male,  of  epi- 
and  hypospadias,  infantile  condition  of  the  penis,  and  crypt- 
orchism  ;  in  the  female,  an  infantile  condition  of  the  uterus  is 
generally  present,  and  the  ovaries  are  often  fibrous.  Cloacal 
openings  have  been  observed  in  both  sexes.  Supernumerary 
mammae  are  common. 

Anomalies  of  Physiological  Function. 

It  is,  of  course,  to  be  expected  that  organs  which  are  the  site  of 
grave  defects  of  structure  or  anomalies  of  anatomical  develop- 
ment should  also  be  imperfect  in  their  physiological  function. 
Thus,  the  condition  of  the  heart  leads  to  an  enfeebled  circula- 
tion^ so  that  cyanosis  and  coldness  of  the  extremities,  chilblains, 
and  sores  are  exceedingly  common.  Defects  of  the  organs  of 
special  sense  are  a  factor  in  producing  a  diminished  perceptivity. 
Xon-development  of  cortical  areas  or  the  internal  structures  of 

*  See  Pringle,  British  Journal  of  Dermatology,  1890,  vol.  ii.,  and  Crocker, 
"  Diseases  of  the  Skin,"  1893. 


90  Mental  Deficiency 

the  encephalon  cause  various  degrees  of  paralysis,  with  their 
accompanying  deformities.  Indeed,  the  mental  deficiency  itself 
may  be  considered  asjinAmperi^^  function  due 

to  neuronic  changes,  whilst  the  various  neuroses  and  psychoses, 
such  as  insanity,  epilepsy,  hysteria,  and  one-sided  genius,  as  well 
as  the  moral  perversions,  seen  in  prostitution,  inebriety,  and 
other  anti-social  and  criminal  tendencies,  are  of  the  same  order. 

With  regard  to  the  functions  of  the^^enexative-Drgans,  there  is 
no  doubt  that  many  of  fh^  persons  can  propagate  their  kind, 
and  there  are,  unfortunately,  numerous  examples  where  this  has 
taken  place.  The  milder  aments,  indeed,  appear  to  be  unusually 
prolific.  At  the  same  time,  in  the  male  sex,  fhe  advent  of 
"puBerty  is  often  considerably  delayed,  and  may  not  appear  until 
fate  in  the~teens.  In  the  male  this  subject  has  been  very  fully 
investigated  by  Bourne ville  and  Sollier,*  who  drew  attention  to 
a  considerable  retardation  of  puberty,  as  well  as  to  the  presence 
of  frequent  anatomical  anomalies  like  those  referred  to.  In  the 
female,  ^n  the  oth'er  hand,  a  similar  retardation  does  noJ:_app,eaL 
to  beTiie  case,  and  it  is  stated  by  Jules  Voisin,f  who  has  studied 
the  subject  closelyrthat  the  development  of  puberty  takes  place 
at  a  normal  age,  and  that  menstruation  recurs  at  regular  periods. 
Doubtless  of  many,  or  even  most,  female  aments  this  is  true,  and 
amenorrhoea  and  dysmenorrhoea^o  not  appear  to  be  cornmoner 
in  them  than  in  those  of  normal  intelligence, ;  indeed,  the  latter 
se'^ms  to  be  less  so.  It  is,  however,  to  be  remembered  that  in 
some  of  the  pronounced  idiots  menstruation  never  appears  at  aU. 

A  similar  retardation  of  physiological  activity  is  seen  with 
regard  to  dentition,  speech,  and  walking.  Inquiries  show  that^  a 
large_proportion  of  aments  do  not  cut  their  first  or  second  teeth 
until  some~7;Dtt»iderabl€  time  after  the  ordinary  period.  Many 
ofthein3[o"TlDt  attempt  to  stand  until  their  third  year,  and 
walking  is  correspondingly  late.  In  many  cases  the  child  is  four 
or  five  years  old  before  it  says  a  word. 

But  in  addition  to  these  functional  defects  of  particular  organs, 
many^  aments  are  characterized  by  a  physiological  inadequacy 
which  is  general  and  widespread.     Their  temperature-regulating 

*  Bourneville  and  SoUier,  "Anomalies  des  Organes  Genitaux  cliez  les 
Idiots  et  les  Imbeciles,"  Progris  MMical,  1888. 
I   Jules  Voisin,  "  L'Idiotie." 


The  Physical  Characteristics  of  Amentia     91 

mechanism  is  so  imperfect  that  colds  and  chills  are  exceeding 
common.  Their  metabolism  is  so  defective  that,  in  spite  of 
abundance  of  wholesome  food,  most  of  them  remain  small, 
stunted,  and  ill-nourished.  They  have  an  increased  pi:e.disposi- 
tion  to  illness,  and  readily  contract  disease,  and  their  physi<> 
logical  margin  and  power  of  resistance  are  so  diminished  that 
"disease  quickly  proves  fatal.  In  fact,  the  history  of  a  very  large 
proportion  of  these  patients  may  be  expressed  in  two  words — 
defectvue  vitality — and  the  supervision  of  the  physician  is  often 
as  necessary  for  their  bodily  as  for  their  mental  ailments.  Lang- 
don  Down  remarked  the  fact  that  ".many  cases  of  irnbecility, 
particularly  those  of  the  Mongolian  variety,  lose  a  large  amount 
of  intellectual  energy  in  the  winter — go  through,  in  fact,  a  process 
of  hybernation,  their  mental  power  being  always  directly  as  the 
external  temperature." 

Mortality. 

The  physical  welfare  of  the  ament  of  to-day  is  the  subject  of 
far  more  care  and  attention  than  was  the  case  a  few  generations 
back.  Then  many  perished  who,  under  present  conditions, 
would  have  survived  ;  and  there  can  be  no  doubt  that  modern 
medical  and  surgical  practice,  together  with  advances  in  pre- 
ventive  medicine,  have  diminished  the  mortality  rate,  not  only 
of  the  fit,  but  of  the  unfit  also. 

Nevertheless,  the  virility  of  aments  as  a  class  is  decidedly 
inferior  to,  and  then-  expecfatiori"W  lifers  till  less  than,  that  of 
the  ordinary  population."  Even  amid  the  well-ordered  sur~ 
roundings  of  an  institution  the  number  of  these  persons  of  at  all 
advanced  age  is  relatively  small,  and  in  the  world  outside  the  pro- 
portion is  still  less.  I  am  disposed  to  think  that  the  mortality  has^ 
generally  speaking,  a  direct  relation  to  the  degree  of  deficiency.  [^ 

This  diminished  expectation  of  life  is  well  shown  by  some 
figures  collected  by  Dr.  Shuttleworth*  with  regard  to  Earlswood 
and  the  Royal  Albert  Asylums.  These  are  shown  in  the  fol- 
lowing table,  together  with  the  mortality  at  corresponding  age 
periods  of  the  whole  population,  as  given  by  the  Registrar- 
General.  The  difference  between  the  mortality  of  aments  and 
the  general  population  is  very  striking. 

*  Quoted  by  Ireland. 


92 


Mental  Deficiency 


TABLE  IX. 

Relative  Mortality  of  Aments  and  Non-Aments. 


Age    Periods. 

Death-Rate  per   1,000. 

Aments  (Dr.  Shuttle- 
worth). 

Whole  Population 
(Registra;  -General). 

5  to  lo  years    . . 
lo    ,,    15 
15    ,,    20      ,, 

50- 1    ' 

33-9 

45-1 

6- 10 
3-35 
4-75 

With  regard  to  age  periods,  through  the  kindness  of  Dr.  C. 
Caldecott,  Medical  Superintendent,  and  Dr.  F.  H.  Pearce, 
Assistant  Medical  Officer,  Earlswood  Asylum,  I  have  been 
supplied  with  particulars  of  1,000  consecutive  deaths  in  that 
institution.  Owing  to  the  impracticability  of  ascertaining  the 
number  of  persons  alive  at  corresponding  ages,  these  figures 
cannot,  of  course,  be  compared  with  the  mortality  tables  relating 
to  the  general  population.  They  are,  nevertheless,  of  consider- 
able interest,  and  are  shown  in  the  following  table  : 


TABLE  X. 

Showing  Age  Periods  of  1,000  Consecutive  Deaths  in  Earlswood 
Asylum,  dating  back  from  October,  1907.* 


Males, 

Females. 

Under       5  years     . 

2 

I 

5    to      9     , 

70 

40 

10     , 

,     14     . 

162 

71 

15     , 

,     19     , 

180 

lOI 

20     , 

,     24     , 

88 

42 

25     > 

.     34     , 

66 

38 

35     . 

.     44     , 

37 

28 

45     . 

.     54     . 

22 

12 

55     . 

.     64     , 

. 

20 

9 

65     . 

.     74     . 

6 

4 

75     . 

,     84     , 

— 

I 

Total 

653 

347 

i,c 

)00 

*  Patients  under  the  age  of  six  are  not  eligible  for  the  institution, 
excepting  those  that  come  in  on  payment  scales. 


The  Physical   Characteristics  of  Amentia     93 

The  following  table,  also  kindly  supplied  by  Dr.  Caldecott,  is 
of  interest  as  showing  the  percentage  of  deaths  to  the  number  of 
patients  in  residence  at  Earlswood  Asylum  over  a  period  of 
seventeen  years.  It  is  impossible  by  means  of  these  figures  to 
institute  an  accurate  comparison  between  the  mortality  of 
aments  and  of  the  general  population,  for  the  reason  already 
mentioned  ;  nevertheless,  they  afford  clear  evidence_ofJ:he ^,ex^ 
cessive  mortality  rate_in_aments.  The  crude  annual  death-rate 
per  1,000  persons  living,  of  all  ages  and  both  sexes,  in  England 
and  Wales  varies  with  different  decennia,  but  is  well  under  20, 
whereas  we  see  that  even  in  a  well-equipped  and  excellently 
managed  institution  like  Earlswood  the  average  mortality  is 
over  30  per  1,000,  and  this  relates  to  a  selected  age  class,  there 

TABLE  XL 

Showing  the  Percentage  of  Deaths  to  the  Number  of  Patients  in 
Residence  at  Earlswood  Asylum  over  a  Period  of  Seventeen 
Years,  from  December  31,   1890,  to  December  31,   1906. 


1 

Year. 

Average  Number 
Resident. 

Died. 

Percentage  of  Deaths 

to  Average 
Number  Resident. 

Males. 

Females. 

Total. 

Males. 

Females. 

Total. 

Males. 

Females. 

Total. 

1890 

418 

191 

609 

8 

7 

15 

I-9I 

3-66 

2-46 

1891 

443 

192 

635 

7 

9 

16 

1.58 

4-68 

2-56 

1892 

426 

186 

612 

13 

6 

19 

3-05 

3-22 

3-IO 

1893 

395 

191 

586 

18 

8 

26 

4-55 

4- 18 

4-42 

rri 

1894 

385 

187 

572 

14 

12 

26 

3-63 

6-88 

4-37 

^ 

1895 

391 

185     , 

576 

5 

5 

10 

2-04 

3-24 

2-40 

1896 

388 

188     1 

576 

12 

8 

20 

3.09 

4-25 

3-40 

1897 

381 

191 

572 

10 

7 

17 

2-88 

3-66 

3-14 

M 

1898 

366 

188 

554 

13 

7 

20 

3-50 

3.72 

3-61 

Q 

1899 

366 

180 

546 

10 

7 

17 

2-73 

3-80 

3-11 

bo 

1900 

346 

183 

529 

II 

4 

15 

3-17 

2-l8 

2-83 

W 

1901 

332 

178 

510 

8 

7 

15 

2-40 

3-93 

2-93 

1902 

336 

179 

515 

6 

7 

13 

1.78 

3-91 

2-52   1 

1903 

339 

174 

513 

9 

12 

21 

2.65 

6-89 

4-09 

1904 

330 

155 

485 

20 

9 

29 

6-00 

5-80 

5-99 

1905 

314 

142 

456 

,    II 

6 

17 

3-50 

4- 20 

3- 70 

1 

1906 

1  '" 

142 

45  3 

7 

10 

17 

2-25 

7-04 

3-75 

94 


Mental   Deficiency 


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The   Physical   Characteristics   of  Amentia       95 


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96 


Mental  Deficiency 


being  a  disproportionately  small  number  of  persons  over  middle 
age  and  practically  none  under  six  years,  so  that  the  two  most 
vulnerable  life  periods  are  excluded. 


Causes  of  Death. 

I  am  greatly  indebted  to  Dr.  Caldecott  and  Dr.  F.  H.  Pearce 
for  supplying  me  with  the  particulars  of  the  cause  of  death  in 
1,000  consecutive  deaths  at  Earlswood  Asylum  which  are  shown 
in  Table  XII.  These  figures  are  not,  of  course,  to  be  con- 
founded with  the  mortality  rates  of  these  diseases.  Neverthe- 
less, they  are  exceedingly  valuable  as  showing  the  relative 
incidence  of  various  fatal  diseases  in  aments. 

It  is  seen  from  this  table  that  by  far  the  co^SioiJiie&lx^use-oi 
d£athis,_lLite:;culosis^Avhich  accounts  for  39*6  per  cent.,  or  nearly 
two^fifths,  of  those  dying.  The  fatal  varieties'oTThis  disease  are 
as  follows  : 


Pulmonary  Tuberculosis 
General                   ,, 
Meningeal                „ 
Abdominal              ,, 
Osseous 

Males. 

Females. 

Total. 

199 

Z7 
10 

9 
6 

106 

I 
8 
3 

305 

54 
II 

17 
9 

261 

135 

396 

Th^  iiexl^  fpost  commoncause^fdeath  is  epileptic  _convulsions. 

which/claims 177  per  cent,  of  the  total  ;  whilst  ^pneumoina  is  a 

very  good  third,  being  responsible  for  10*4  per  cent,  of  total 
deaths.  It  is  interesting  to  note  that,  excluding  tubercle,  the 
nervous  system  is  the  part  most  frequently  involved  bj  fatal 
disease,  being  followed  in  order  by  the  respiratory,  circulatory, 
alimentary,  and  urinary  systems.  Not  that  diseases  or~the 
nervous  system  are  the  cause  of  the  mental  deficiency,  but  because 
('the  imperfection  of  development  and  imperfect  functioh"oT  the 
^ervous  system  render  it  peculiarly  prone  to  disease. 
^  T  do  not  profess  to  institute  an  accurate  comparison  between 
the  frequency  of  the  various  causes  of  death  in  these  aments  and 


The  Physical  Characteristics  of  Amentia     97 

in  the  general  population.  Such  is  impossible,  for  many  reasons 
which  will  at  once  be  obvious  to  the  student  of  vital  statistics. 
It  may  be  stated,  however,  that  according  to  various  Reports  o^ 
the  Registrar-General,  it  appears  that  of  the  total  deaths  through^ 
out  "England  and  Wales  approximately  12  per  cent,  are  due  to 
diseases  of  the  nervous  system  ;  8  £er  cent,  of  the  circulatory 
system  ;  18  per  cent,  of  the  respiratory  system  ;  5  per  cent,  of 
the'  digestive  system  ;  and  2  per  cent,  of  the  urinary  system  ; 
whilst  from  10  to  12  per  cent,  are  due  to  pulmonary  and  other 
forriis  of  tuberculosis.  In  these  aments,  on  the  other  hand, 
23*6' per  cent,  of  the'total  deaths  are  from  diseases  of  the  nervous  ; 
4*9  per  cent,  of  the  circulatory ;  I2"6  per  cent,  of  the  respiratory  ; 
4*3  per  cent,  of  the  digestive  ;  and  i*i  per  cent,  of  the  urinary 
systems  ;  whilst  39*6  per  cent,  are  due  to  some  form  of  tubercu- 
losis. 


CHAPTER  VII 

NERVOUS  AND  MENTAL  CHARACTERISTICS  OF  AMENTU 

In  addition  to  their  general  deficiency  of  intellect,  many  aments 
present  certain  other  particular  and  important  psychological 
anomalies,  as  well  as  irregularities  and  defects  of  sensory  and 
motor  function.  These  will  be  described  in  the  present  chapter  ; 
in  so  doing,  it  will  be  convenient  to  consider  them  under  the  three 
headings.  Sensory,  Mental,  and  Motor  Processes. 

Sensory  Processes. 

The  brain  of  the  new-born  child  consists  of  a  gelatinoid  sub- 
stance in  which  are  imbedded  myriads  of  embryonic  nerve  cells. 
These  cells,  or  neuroblasts,  however,  are  so  immature  that  the 
child  may  be  said  to  be  mindless.  Mental  development  proceeds 
by  slow  and  orderly  steps,  and  one  of  the  most  important  means 
by  which  it  is  brought  about  is  the  stimulation  of  these  cells  by 
impressions  entering  through  the  sensory  channels.  Should  one 
of  the  senses  be  diseased  or  defective,  a  corresponding  area  of 
Ithe  brain  will  remain  permanently  undeveloped,  and  this  may 
lead  indirectly  to  thelToiTdevelopmentof  other  portions  which 
are  lunctionally  correlated.  Should  communication  witn  the 
outer  world  be  closed  via  several  sensory  pathways,  the  growth 
of  the  brain  may  be  so  much  interfered  with  as  to  produce  a 
condition  almost  amounting  to  idiocy,  and  known  as  '*  amentia 
by  sense  deprivation."  As  instances  of  this,  the  celebrated 
cases  of  Kaspar  Hauser  and  Laura  Bridgman  may  be  referred 
to.  Considered,  therefore,  merely  from  the  point  of  view  of 
their  stimulating  effect  upon  the  brain  cells,  sensory  impressions 
are  as  necessary  to  mental  development  as  are  the  rays  of  the 
sun  to  the  growth  and  maturation  of  plant  life. 

98 


Nervous  and  Mental  Characteristics  of  Amentia  99 

This,  however,  is  not  their  only  effect.  Sensations  .are  the 
basis  of  ideas,  and  a  comparison  of  ideas  constitutes  reasoning  ; 
so  that  although  the  ability  to  receive  impressions  and  the 
ability  to  examine,  combine,  compare,  and  work  up  these  impres- 
sions are  two  totally  distinct  functions,  yet  the  wealth  of  sensa- 
tions is  a  factor  which  cannot  be  ignored  in  considering  the 
quantity,  if  not  the  quality,  of  mental  activity.  In  somewhat 
crude  language,  we  may  say  that  sensations  are  the  materials 
of  which  "  mind  "  is  built,  and,  in  their  absence,  the  brain  cells 
are  probably  incapable  of  producing  a  single  idea.  SensatioiA 
may  be  present  without  reason,  but  reason  cannot  exist  withy 
out  sensation. 

Although  it  is  convenient  to  divide  the  total  cerebral  activity 
into  three  groups  of  processes — viz.,  sensory,  mental,  and  motor 
— these  are  all  interdependent.  If  the  more  purely  psychological 
functions  are  defective,  not  only  will  outgoing  currents  be  altered, 
but  the  accuracy  and  extent  of  sensations  may  be  greatly  inter- 
fered with.  Attention  in  particular  has  a  most  important 
influence  upon  sensation,  and  many  of  the  sensory  defects  of 
aments  are  due,  not  merely  to  defects  of  the  sensory  mechanism 
proper,  but  to  imperfections  of  the  higher  neuronic  activities 
of  the  brain. 

There  are  three  elements  concerned  in  sensation  :  a^oeripheral 
sense  organ,  a  transmittin^jierve^nd  a  central  receptive  gan- 
glionic area.  With  regard  to  the  nerve,  beyond  diminished  size, 
I  know  of  no  structural  differences  between  aments  and  normal 
persons.  The  peripheral  sense  organ  is  not  infrequently  the 
seat  of  disease  or  anomalies  of  development  which  may  either 
completely  cut  off,  or  seriously  interfere  with,  a  particulai 
order  of  impressions  ;  but  the  chief  cause  of  sensory  imperfections 
in  these  persons  lies  in  a  defeclivexondition^of  the  central  recep- 
tive ganglion  cells  or  of  the  still  higher  perceptive  mechanism. 

Sensation  varies  very  much  in  aments,  and  on  the  whole  is 
directly  proportionate  to  the  degree  of  mental  deficiency.  In 
the  feeble-mindedsensoix_d^fectsj£e__b^^ 
t;hTpfly<2f_^_d^'miTii<^bp(^  r^^Pfrf^  and  acutf  ri  p.j^'n  In  imbeciles  more 
or  less  actual  obtuseness  of  the  senses  is  seer^  :  whilst  in  idiots 
this  often  reaches  such  an  extreme  degree  that  one  or  more  of 
the  senses  seern  to  be  actually  w^a^^tlrg 

■^  7—2 


loo  Mental  Deficiency 

Generally,  apart  from  the  presence  of  disease  or  congenital 
anomaly  of  a  particular  sense  organ,  the  defect  is  uniformly 
incident  upon  all  the  senses  ;  but  to  this  there  are  some  remark- 
able exceptions,  as  will  be  seen  in  a  subsequent  chapter. 

Vision. — The  chief  peripheral  defects  have  already  been 
described  ;  they  are  strabismus,  corneal  ulcers  and  opacities, 
cataract,  astigmatism,  hypermetropia,  and,  less  frequently, 
myopia.  A  few  low-grade  aments  are  congenitally  blind,  but 
colour-blindness  does  not  appear  to  be  commoner  than  in  normal 
persons.  These  conditions,  and,  indeed,  all  anomalies  of  the 
end  organs  of  special  sense,  are  more  frequent  in  the  severer 
grades  of  mental  deficiency. 

In  the  milder  degrees  of  amentia  visual  defects  consist  chiefly 
in  an  inability  to  discriminate  between  the  slighter  differences 
of  form,  size,  or  colour.  An  octagonal  will  be  confused  with 
a  hexagonal  figure  ;  no  difference  will  be  noticed  between  the 
size  of  a  florin  and  half-crown  ;  and,  although  these  patients  may 
differentiate  between  the  primary  colours,  they  are  often  unable 
to  detect  differences  of  shade.  As  we  proceed  down  the  scale  of 
amentia,  these  defects  become  more  marked,  until  in  the  severe 
forms  of  idiocy  they  exist  to  a  very  pronounced  extent.  The  colour 
perception  of  the  low-grade  imbecile  and  idiot  often  seems  limited 
to  the  recognition  of  red,  and  it  is  interesting  to  note  that  this 
is  the  colour  which  is  usually  most  attractive  to,  and  first  recog- 
nized by,  the  normal  child.  The  appreciation  of  form  and  size 
by  idiots  is  very  imperfect,  and  although  they  will  distinguish 
between  a  child  and  a  grown-up  person,  and  between  a  man  and 
a  woman,  many  of  them  are  incapable  of  any  more  delicate 
differentiation.  Voisin  states  that  in  most  imbeciles  the  per- 
ception of  relief  is  wanting. 

Hearing. — Developmental  anomalies  of  the  external  ear  are 
very  numerous,  but  it  is  very  rarely  that  such  interfere  with 
hearing.  Where  there  is  a  peripheral  cause  for  deficiency  of 
this  sense,  it  is  nearly  always  of  inflammatory  origin  and  situate 
in  the  middle  ear.  Otorrhoea  occurs  with  considerable  frequency 
in  aments  of  all  grades. 

Apart  from  cases  of  amentia  due  to  sense  deprivation,  complete 
deafness  is  not  common  in  the  mentajly  defective.  Some  idiots 
and  imbeciles  will  pay  not  the  slightest  regard  to  questions,  to 


Nervous  and  Mental  Characteristics  of  ArUcritia  loi 

the  sound  of  a  whistle,  or  noises  of  many  kinds,  and  they  are 
on  that  account  often  thought  to  be  deaf.  That  this  is  due  to 
want  of  interest  and  attention,  however,  and  not  to  deafness,  is 
often  shown  by  the  fact  that  they  will  at  once  turn  upon  the  rattle 
of  a  spoon  and  plate.  Itard's  wild  boy  of  Aveyron  was  unre- 
sponsive to  many  sounds,  and  yet  he  showed  a  marvellous  apti- 
tude for  hearing  those  in  which  he  was  interested.  In  the 
feeble-minded  grade  of  amentia  there  is  not  usually  any  marked 
deficiency  of  this  sense,  although  hearing,  as  a  rule,  is  neither  so 
acute  nor  are  the  finer  differences  of  tone  so  well  detected  as  by 
the  normal  person. 

Taste. — In  the  milder  aments  there  is  not  usually  any 
marked  impairment  of  this  sense,  although  I  doubt  whether 
they  have  the  delicacy  of  taste  of  an  ordinary  person.  They 
have  their  likes  and  dislikes  with  regard  to  food,  and  they  appre- 
ciate sweets  and  object  to  nasty  medicines.  In  the  more  severe 
grades  there  is  often  an  extreme  defect  of  taste,  whilst  in  many 
cases  there  is  marked  perversion  of  this  sense.  Thus,  some 
idiots  will  munch  sugar,  quinine,  or  even  soap,  quite  indifferently, 
and  without  the  slightest  indication  that  they  distinguish  one 
from  the  other.  Others  will  eat  and  drink  anything  which  comes 
within  their  reach,  including  wood,  leather,  grass,  earth,  stones, 
even  urine  and  faecal  matter  or  offal  of  the  most  putrid  descrip- 
tion. 

One  of  the  chief  characteristics  of  the  Mongolian  variety  is  a 
large  fissured  tongue,  with  hypertrophied  papillae,  but  this  does 
not  appear  to  be  accompanied  by  any  particular  anomaly  of 
taste. 

Smell. — This  sense  is  closely  related  to  the  preceding.  In  the 
milder  aments  ability  to  perceive  odours  is  present,  but  is  lacking 
in  delicacy.  In  the  more  severe  grades  there  often  seems  to 
be  a  complete  absence  of  the  sense.  Many  idiots  will  smell  the 
most  filthy  compounds  without  the  slightest  sign  of  repugnance, 
and  some  will  sniff  strong  ammonia  without  any  reflex  move- 
ment. In  these  latter  a  defective  condition  of  the  olfactory 
mucous  membrane  would  appear  to  be  present. 

Cutaneous  and  Muscle  Sensibility.  —  The  milder  defectives 
can  differentiate  by  the  sense  of  touch  between  bodies  which  are 
hard  or  soft,  rough  or  smooth,  but  they  cannot  appreciate  the 


I  c>2   ' '  '''"'•'' '    '- '  ^ Mental  Deficiency 

finer  gradations  of  these  qualities  so  well  as  the  normal  child. 
The  same  remark  applies  to  the  sensation  of  pressure,  as  tested 
by  weights  or  small  pill-boxes  filled  with  a  varying  number 
of  coins  or  shot,  and  placed  on  the  palm  of  the  hand.  In  the 
imbeciles  this  sense  of  discrimination  is  still  less  acute  ;  but 
this  may  be  apparent  only,  and  due  to  the  difficulty  of  examina- 
tion.    In  the  idiots  such  a  test  is  practically  impossible. 

Alterations  of  temperature  are  certainly  appreciated  by  the 
mild  aments,  but  in  many  of  the  idiots  this  capacity  seems  to  be 
wanting.  They  will  sit  in  front  of  the  hottest  fire,  under  the 
most  blazing  sun,  or  exposed  to  the  coldest  wintry  blast,  without 
showing  any  concern.  Pain  is  experienced  by  feeble-minded 
children  ;  they  will  complain  of  headache,  toothache,  or  stomach- 
ache, but  such  sensations  are  often  not  so  acute  as  in  normal 
children,  and  many  of  the  feeble-minded  will  suffer  the  extraction 
of  teeth  and  other  operations  of  minor  surgery  with  relatively 
little  concern.  In  the  pronounced  imbeciles,  and  more  particu- 
larly in  idiots,  inability  to  feel  pain  is  often  a  very  marked 
characteristic.  There  are  many  idiots  who  will  knock  themselves 
against  floor  or  walls,  poke  their  fingers  into  their  eyes,  pull  out 
their  hair,  teeth,  or  toe-nails,  and  injure  themselves  severely  in 
many  ways,  without  showing  the  slightest  indication  that  the 
process  is  painful.  I  knew  a  boy  some  years  ago  who  had  such 
an  incurable  habit  of  sucking  his  fingers  that  the  bone  had  been 
completely  denuded  of  flesh,  yet  the  practice  seemed  to  afford 
him  extreme  pleasure  rather  ,than  discomfort.  It  is  practically 
impossible  to  make  any  experimental  inquiries  as  to  the  condition 
of  muscle,  tendon,  and  joint  sensations  in  these  persons  ;  but, 
judging  from  their  general  clumsiness  of  manipulation,  bodily 
balance,  and  movement,  one  is  justified  in  assuming  that  such 
cannot  be  of  a  very  high  order. 

Organic  Sensations. — The  sexual  instinct  is  by  no  means 
absent  in  the  feeble-minded,  also  in  many  imbeciles,  and  even  in 
some  idiots  ;  indeed,  in  some  of  the  milder  degrees  it  is  often 
inordinately  developed.  In  the  profound  idiots  such  primitive 
organic  sensations  as  those  of  hunger  and  thirst  are  wanting, 
and  such  persons  would  die  of  starvation  if  not  fed.  On  the  other 
hand,  many  of  the  partial  idiots  are  extraordinarily  gluttonous 
and  voracious.      In  the  lower    types    the    painful    sensations 


Nervous  and  Mental  Characteristics  of  Amentia  103 

which  accompany  organic  disease  are  often  not  appreciated,  and 
these  persons  will  be  acutely  ill,  with  pneumonia,  gangrene  of  the 
lung,  or  tuberculosis,  without  making  any  complaint.  In  such 
cases  there  will  be  no  subjective  symptoms  to  guide  the  physician, 
and  his  diagnosis  will  have  to  depend  entirely  upon  objective 
signs. 

IVt^ntal  Pcficesses^ 

The  essence  of  amentia  is  a  defective  development  of  the 
neurones  which  are  the  physical  basis  of  the  internal  and 
more  purely  psychological  functions  ;  these  we  have  now  to  con- 
sider. In  many  cases  disorders  of  sensation  or  motion  are 
present  as  well ;  but  in  the  mildest  examples  these  mental  pro- 
cesses alone  may  suffer.  In  some  instances  we  can  even  point 
to  a  special  default  of  some  one  particular  function,  such  as  that 
of  attention,  imagination,  memory,  etc.  ;  but  the  mind  cannot 
be  thus  divided  into  watertight  compartments,  and  no  particular 
defect  can  exist  without  disturbing  the  harmonious  working  or 
potentiality  of  the  mind  as  a  whole. 

Attention. — The  act  of  attention  consists  in  the  focussing  of  con- 
sciousness upon  an  idea  or  the  mental  image  of  an  object,  to  the 
exclusion  of  other  ideas.  It  may  be  spontaneous  and  involuntary 
or  active  and  voluntary,  and  it  is  necessary  to  consider  these 
separately. 

Spontaneous  attention  occurs  when  a  sensation  or  idea  is  so 
suH3en,  so  intense,  or  so  unusual,  that  it  holds  consciousness 

^reHSyand  without  any  mental  effort^ Of  this  nature  is  the 

flash  of  lightning,  the  peal  of  thunder,  or  any  sight  or  other  sensa- 
tion to  which  the  beholder  is  utterly  unaccustomed.  This  form 
of  attention  is  characteristic  of  children  and  the  lower  animals, 
and  although,  of  course,  dependent  upon  the  nature  of  the 
stimulus,  variations  in  it  are  more  influenced  by  the  condition  of 
the  cerebral  cells  with  regard  to  their  inherent  excitability.  It 
may  be  compared  to  the  violent  shock  inflicted  upon  the  cerebral 
mass  of  the  child  of  a  few  weeks  old  by  any  sudden  noise,  and 
which  results  in  a  general  start  of  the  whole  body  ;  with  the 
development  of  consciousness  this  general  bodily  change  is  often 
still  seen  when  attention  is  involuntarily  aroused. 

In  the  lowest  type  of  idiocy  feeling  is  very  rudimentary,  and 
hence   even   this  spontaneous   form  of  attention  is  defective. 


I04  Mental  Deficiency 

But  even  where  perception  is  present  the  cerebral  excitabiHty 
may  be  so  diminished  as  to  bring  about  a  considerable  deficiency 
of  spontaneous  attention,  and  this  is  the  case  with  many  idiots 
and  imbeciles  as  well  as  with  a  few  feeble-minded.  Such  persons 
are  dull  and  lethargic  ;  they  seem  to  be  utterly  unconcerned  by 
anything  happening  around  them,  and  they  have  no  curiosity 
or  initiative.  If  in  school,  they  sit  at  their  desks  gazing  vacantly 
in  front  of  them  ;  if  in  the  playground,  they  stand  aloof  in  a  corner, 
without  the  slightest  desire  to  take  part  in  the  games  of  their 
companions.  They  respond  tardily,  or  not  at  all,  when  addressed, 
are  stolidly  indifferent  when  interfered  with,  and  are,  in  fact, 
so  generally  inert  as  to  give  rise  to  the  impression  that  they  are 
deaf.  But  there  is  no  real  sensory  defect,  and  the  condition  is 
simply  one  of  general  brain  inertia.  By  appropriate  methods 
of  training,  the  excitability  of  the  brain  cells  may  often  be  in- 
creased and  the  child  aroused  out  of  his  lethargy. 

Active  or  voluntary  attention  takes  place  wheivthejdeajor  sensa- 
tion attended  to  has  no  compelling  power  of  its  own.  Attention 
to  it  may,  indeed,  be  distasteful,  and  the  focussing  of  consciousness 
upon  it,  so  that  other  ideas  and  impressions  are  for  the  time  being 
shut  out,  demands  a  very  considerable  voluntary  effort.  It  is 
plain  that  attention  of  this  kind  is  indispensable  to  the  acquire- 
ment of  knowledge  and  the  conduct  of  human  affairs,  and  the 
person  in  whom  it  is  greatly  lacking  will  cut  but  a  sorry  figure  in 
life. 

This  is  the  case  with  a  large  number  of  aments.  They  are 
quite  incapable  of  concentrating  their  thoughts  upon  a  particular 
subject,  and  they  consequently  have  no  power  for  sus^ain^d 
work.  It  follows  that  their  education  and  training  is  exceedingly 
difficult.  Persons  of  this  type  differ  from  those  lacking  in  spon- 
taneous attention  in  several  noteworthy  points.  Instead  of 
being  heavy  and  lethargic,  they  are  often  active  and  restless,  and 
attracted,  but  distracted,  by  every  sight  and  sound  around  them. 
The  condition  is  thus  the  exact  opposite  of  the  former  type,  and 
at  first  sight  would  appear  to  result  from  an  excessive,  instead  of 
diminished,  nervous  excitability.  This,  however,  is  by  no  means 
necessarily  the  case,  and  very  often  the  fault  seems  to  lie  rather 
in  a  defective  power  of  co-ordination  and  control.  It  is  often 
associated  with  the  presence  of  tricks  and  habits.     As  Maudsley 


Nervous  and  Mental  Characteristics  of  Amentia  105 

says,  "  The  person  who  is  unable  to  control  his  own  muscles  is 
incapable  of  attention." 

This  condition  of*  imperfect  muscular  control  and  defective 
attention  is,  of  course,  characteristic  of  normal  infancy  ;  but 
■  whereas  it  is  but  a  phase  in  the  development  of  the  healthy  child, 
it  is  a  much  more  persistent,  and  often  permanent,  condition  in 
the  mentally  defective.  It  is  undoubtedly  responsible  for  much 
of  the  faulty  perception  and  discrimination  of  these  persons, 
and,  since  our  stock  of  ideas  is  dependent  upon  the  multi- 
plicity and  accuracy  of  sensations  from  the  outer  world,  some 
would  see  in  this  defective  power  of  attention  the  psychological 
fons  et  origo  of  mental  deficiency.  But,  whilst  admitting  to  this 
faculty  a  most  important  share  in  the  quantity  and  quality  of 
the  intellectual  processes,  its  lack  in  these  persons  is  not  sufficient 
to  account  for  their  imperfect  reason  and  want  of  common  sense. 
Moreover,  there  are  many  aments  in  whom  attention  is  not 
lacking.  We  must  therefore  consider  the  defective  attention  of 
aments,  not  as  the  prime  cause,  but  as  only  one  factor  of  that 
general  imperfection  of  mental  faculty  which  constitutes  amentia. 

Association  and  Memory. — If  a  healthy,  intelligent  child  of 
between  three  and  four  years  be  asked  to  describe,  from  memory, 
some  common  object— such,  for  instance,  as  a  cat,  a  chair,  or 
table — and  if  a  little  direction  be  given  to  his  thoughts  by  not 
too  leading  questions,  a  very  good  estimate  will  be  formed  as  to 
his  capacity  of  memory  and  association.  To  those  unacquainted 
with  the  mind  of  an  intelligent  child  of  this  age  the  result  is 
often  surprising,  and  contrasts  in  an  extremely  marked  manner 
with  a  similar  examination  of  the  mentally  defective  child  of 
much  greater  age.  I  have  often  found  the  mental  images  in  a 
defective  child  of  twelve  or  even  fourteen  years  to  be  far  simpler, 
and  to  have  only  a  fraction  of  the  associations  which  are  present 
in  the  former  case.  In  the  lower  aments  the  deficiency  is  still 
more  marked,  although  such  an  examination  in  their  case 
is  extremely  difficult.  We  may  therefore  say  that  aments 
generally^rejiecidedly  inferior  ir>  the  power  of  association  and 
recall^-- 

\  No  doubt  much  of  this  is  due  to  a  faulty  perception,  which 
^n  its  turn  may  be  the  result  of  a  defective  attention  and  in- 
capacity for  mental  effort  ;  and  although,  as  we  have  seen  in 


io6  Mental  Deficiency 

speaking  of  pathology,  one  of  the  distinguishing  features  of  the 
ament's  brain  is  a  paucity  of  association  fibres,  it  is  a  moot  point 
whether  this  is  a  primary  deficiency  or  a  secondary  result  of  their 
faulty  perception. 

But  although  there  is  a  diminished  complexity  of  association, 
the  connexions  which  do  exist  seem  to  cling  together  with  a  very 
considerable,  and  at  times  even  extraordinary,  tenacity.  This 
is  shown  in  the  remarkable  powers  of  some  aments  for  repeating 
poetry,  remembering  dates  and  names,  and  other  similar  feats 
of  memory.  Such  instances  are,  of  course,  exceptional ;  but  in 
many  aments  the  general  tenacity  of  memory  for  striking  events 
and  certain  isolated  occurrences  which  have  appealed  to  them 
does  not  seem  to  be  markedly  inferior  to  that  of  the  normal 
person.  In  their  general  power  of  recall,  however,  and  in  their 
ability  to  remember  ordinary  things  and  the  little  occurrences  of 
everyday  life,  there  is,  as  a  rule,  a  decided  defect. 

Imagination. — Fantasy,  reverie,  and  day-dreaming  occur  in 
some  of  the  milder  aments,  although  in  a  much  simpler  form 
than  in  the  normal  person.  Moreover,  many  of  those  of  unstable 
type  have  delusions  without  either  mental  exaltation  or  depres- 
sion. A  few  are  even  capable  of  a  certain  amount  of  constructive 
imagination,  as  is  shown  by  their  skill  in  drawing  and  mechanical 
invention,  as  well  as  by  the  cunning  with  which  they  commit 
thefts  and  the  ingenuity  with  which  they  invent  plausible  lies 
to  screen  themselves  and  incriminate  their  companions.  On  the 
whole,  however,  there  seems  to  be  a  decided  defect  in  the  faculty 
of  imagination  in  aments.  The  higher  types  may  copy  a  drawing 
or  design  ;  they  may  produce  faithful  models  of  flowers  or  fruit  ; 
they  may,  indeed,  have  a  very  high  degree  of  manipulative  skill  ; 
but  their  work  is  generally  a  slavish  imitation,  and  they  hardly 
ever  originate.  And  when  they  do,  the  result  is  not  usually 
creditable  to  their  imagination.  If  mentally  defective  school- 
children be  watched  drawing,  brick-building,  or  pattern-making, 
it  will  generally  be  found  that  they  follow  the  same  stereotyped 
plan,  and  that  they  do  not  evince  a  fraction  of  the  originality 
shown  by  the  normal  child.  In  the  imbeciles  and  idiots  the 
deficiency  is  much  more  pronounced. 

Ideation. — In  view  of  their  defects  of  attention,  perception, 
and  memory,  it  necessarily  follows  that  the  capacity  of  aments 


Nervous  and  Mental  Characteristics  of  Amentia  107 

for  forming  ideas  is  limited,  and  conversation  readily  reveals  the 
general  crudity  and  childishness  of  their  thoughts.  One  may, 
indeed,  say  that  the  intellectual  life  of  these  persons  consists 
almost  entirely  of  perceptions,  and  not  conceptions — that  is,  of 
simple  ideas  relating  to  objects  which  are  immediately  present 
to  their  senses.  I  cannot  agree,  however,  with  the  statement  so 
often  made,  that  the  ament  is  utterly  wanting  in  the  capacity 
for  forming  abstract  ideas.  It  is  true  that  the  concrete  is  much 
more  readily  grasped  than  the  abstract,  and  it  is  interesting  to 
note  that  many  feeble-minded  school-children  find  it  much  easier 
to  express  their  ideas  by  means  of  a  drawing  than  by  a  word  ;  but 
there  is  no  doubt  that  manj^  of  the  milder  grade  are  quite  capable 
of  conceiving  such  universals  as  mankind  and  womankind, 
goodness  and  badness,  and  the  like.  Of  abstracting  in  the  logical 
sense,  however,  most  of  them  are  probably  quite  incapable. 

Judgment  and  Reasoning. — To  reason  is  to  think,  but  thinking 
is  not  reasoning.  Most  of  our  thinking  consists  simply  of  a 
review  of  mental  images  which  successively  rise  into  consciousness 
in  accordance  with  the  laws  governing  association.  The  thought 
which  is  past  has  suggested  that  now  present,  and  this  in  its  turn 
suggests  that  to  come,  the  series  depending  upon  previous 
experience  (perceptions)  and  the  type  of  our  mental  constitution. 
Thinking  is  thus  to  a  great  extent  a  form  of  reverie,  although 
thoughts  may  be  directed  and  confined  to  a  certain  channel  by 
an  effort  of  will. 

Reasoning,  on  the  other  hand,  is  not  only  a  definite  and 
deliberate  effort  of  volition,  but  it  also  involves  other  processes 
which  are  not  concerned  in  mere  thinking.  Without  attempting 
to  discuss  what  these  are,  or  the  manner  of  their  working,  it 
may  be  said,  briefly,  that  reasoning  consists  in,  firstly,  the 
deliberate  contemplation  of  certain  ideas  ;  the  abstraction  from 
these  of  their  essential  attributes ;  the  comparison  of  these  ab- 
stractions ;  and,  finally,  the  construction  of  an  idea  or  judgment 
which  is  new  to  our  mental  experience. 

Reasoning  thus  involves  activities  of  a  higher  order  than  any 

hitherto  considered,    and   the   rhj^   rhar?:irtprkfir   of   amf^r^tia    is 

a  defect  of  these  functions.  ^This  defect  reaches  its  maximum 
in  the  most  pronounced  degree  of  amentia,  and  in  the  majority 
of  idiots  the  ability  to  reason  may  be  said  to  be  completely 


io8  Mental  Deficiency 

absent.  The  absolute  idiots  would  even  die  of  starvation,  in 
the  midst  of  food,  if  they  were  not  fed.  The  feeble-minded,  on 
the  other  hand,  are  by  no  means  destitute  of  this  faculty  ;  for 
instance,  if  a  mentally  defective  child,  who  is  ignorant  of  money 
values,  be  offered  the  choice  of  a  shilling  or  half-crown,  he  may 
choose  the  latter  "  because  it  is  bigger." 

Upon  asking  a  feeble-minded  adult,  whose  daily  work  con- 
sisted in  cleaning  the  type  in  the  printing-room,  what  he  was 
cleaning  it  with,  he  said,  "  Turps."  Upon  then  asking  him  what 
he  washed  his  hands  with,  he  replied,  "  Soap  and  water."  But 
he  was  for  a  time  quite  nonplussed  when  asked  why  "  turps  '' 
wouldn't  do  for  his  hands,  or  "  soap  and  water  "  for  the  type. 
At  length,  however,  after  much  floundering,  I  got  out  of  him 
that  soap  and  water  wouldn't  get  the  ink  off  the  type,  and  that 
turpentine  would  make  his  hands  sore.  Nevertheless,  although 
these  persons  possess  some  power  of  reasoning,  it  is  so  limited 
that  they  are  quite  unable  to  steer  a  course  upon  life's  sea,  or 
even  to  keep  their  heads  above  water,  without  support. 

The  imbeciles,  as  a  class,  are  intermediate  between  these  two 
extremes.  I  sent  a  feeble-minded  and  an  imbecile  youth  respec- 
tively to  fetch  an  article  out  of  a  room,  the  door  of  which  had 
been  locked  and  the  key  hung  up  in  a  conspicuous  place  above 
the  handle.  The  feeble-minded  one  went  to  the  door,  tried  the 
handle,  found  it  locked,  seemed  nonplussed  for  a  moment,  then 
saw  and  took  down  the  key,  opened  the  door,  and  performed  his 
task.  The  imbecile  tried  the  door,  gazed  vacantly  at  the  key, 
turned  round,  and  said,  "  Locked."  Upon  being  asked  where 
the  key  was,  he  pointed,  and  said,  "  There,"  but  when  again  told 
what  to  fetch  he  made  no  effort  to  use  the  key.  Upon  my  placing 
the  key  in  the  lock,  he  turned  it,  opened  the  door,  and  got  the 
desired  article,  A  somewhat  similar  test  was  tried  between  two 
other  children.  It  was  a  pouring  wet  day,  and  I  placed  an 
umbrella  near  the  door,  and  told  them  to  fetch  a  certain  flower 
out  of  the  garden.  The  feeble-minded  child  opened  the  door, 
saw  the  rain  coming  down  in  torrents,  and,  after  a  pause,  picked 
up  and  opened  the  umbrella.  The  imbecile  would  have  got  wet 
through  had  he  not  been  called  back,  but,  when  given  the  um- 
brella, had  enough  sense  to  open  it  before  going  out. 

Temperament. — Temperament  is  dependent  upon  physiological 


p 


Nervous  and  Mental  Characteristics  of  Amentia  109 

peculiarities  of  nerve  action,  and  the  mentally  defective  person 
trjust  as  subject  to  differences  in  this  respect  as  is  the  normal. 

Since  the  days  of  Aristotle  it  has  been  customary  to  describe 
four  temperaments — namely  :  "" 

Choleric,  where  the  excitability  is  great  and  after-effect  great.  1 
Sanguine,    where   the   excitability   is   great   and   after-effect 

small. 

Phlegmatic,  where  the  excitabilftv  is  small  and  after-effect 
"■"^small.  / 

Melancholic,  where  the  excitability  is  small  and  after-effect 
great. 


I  cannot  recall  an  ament  who  could  rightly  be  described  as\ 
choleric  ;  most  are  of  the  phlegmatic  type,  some  are  sanguine, 
and  a  few — chiefly  of  the  mildest  grade— are  melancholic. 

Although  most  aments  will  display  a  childish,  and  at  times 
keen,  interest  in_spectacularr  displays,  they  are  not,  as  a~'rule, 
arousedTEereby  to  the  same  pitch  of  enthusiasm  as  a  normal  child. 
Moreover,  the  impression  quickly  fades,  and  they  soon  cease  to  talk 
about  it.  Although  by  no  means  insensible  to  praise  or  blame, 
pleasure  or  punishment,  they  are  not,  as  a  rule,  greatly  affected 
thereby,  and  the  sensation  is  but  fleeting.  Some  of  the  milder 
grades,  it  is  true,  evince  a  considerable  amount  of  mental  perturba- 
tion on  first  leaving  their  friends  for  the  care  of  strangers  ;  but 
they  are  seldom  really  home-sick,  as  is  the  ordinary  child,  andjtliey 
rapidly  settle  down  to  their  new  surroundings  with  hardly  a 
thought  of  the  old.  01  most  of  them  it  may  be  said  that  their 
general  attitude  is  one  of  placid  indifference,  and  that  they  are 

people. 

A  few  may  be  described  as  sanguine.  They  are  quick,  lively, 
and  readily  attracted  by  anything  happening  around  them,  and 
easily  moved  to  laughter  or  tears,  passionate  anger,  or  cloudy 
sullenness.  But  this  state  is  very  fleeting,  and  leads  to  little 
result.  Though  seemingly  full  of  interest  in  everything,  they 
settle  down  to  nothing. 

Another  small  proportion  belong  to  the  melancholic  type. 
In  these,  although  censure,  punishment,  or  neglect  seem  to  make 
little  impression  at  the  time,  the  child  or  adult  becomes  morose, 


no  Mental  Deficiency 

and  begins  to  brood  over  his  real  or  fancied  wrongs.  Sometimes 
a  state  of  true  melancholia  results,  and  I  have  known  several 
persons  of  this  type  who  have  attempted  suicide. 

Emotion  and  Sentiment. — The  emotions  most  commonly  seen 
in  aments  are  the  simple  ones  of  pleasure,  grief,  affection,  anger, 
fear,  and  surprise.  The  more  complex  states  of  shame,  awe, 
contempt,  disgust,  indignation,  hate,  and  jealousy,  are  compara- 
tively rare  and  of  little  intensity.  On  the  whole,  the  capacity  for 
experiencing  emotion  seems  to  be  directly  proportionate  to_thiL 
g^iountof  general  intelligence  present,  although  much  depends 
^pon  the  particular  variety  of  nervous  temperament.  In  the 
^absolute  idiots  emotion  is  lacking  altogether. 

Moral  Sense  is  lacking  in  the  lowest  grade  of  amentia,  and  in 
the  imbeciles  and  feeble-minded  it  rarely  reaches  a  high  degree 
of  development.  Most  of  these  persons  act  upon  the  impulse 
of  the  moment,  quite  unaffected  by  any  altruistic  feelings.  They 
may  develop  the  habit  of  refraining  from  lying  or  pilfering 
because  they  realize  that  such  lead  to  punishment ;  but  the 
majority  do  not  understand  that  any  obligation  i^  morally  due 
from  them,  or  that  they  should  be  virtuous  for  virtue's  sake. 
On  the  other  hand,  a  few  do  acquire  rudimentary  notions  of  un- 
selfishness and  good  behaviour,  and  some,  even,  are  capable  of 
hazy  anthropomorphic  ideas  of  a  Superior  Being,  thus  showing 
the  germs  of  a  religious  sense.  They  may  be  taught,  and  in  a 
simple  way  understand,  the  Bible  stories  ;  they  may  tell  one  that 
after  death  the  good  people  go  to  heaven  and  the  bad  ones  to 
hell,  and  this  belief  may  be  not  without  effect  upon  their  daily 
behaviour  ;  but  of  theological  dogma  or  doctrine  beyond  this 
the  majority  have  little  conception. 

Finally,  as  a  connecting  link  between  mental  and  the  more 
obvious  motor  phenomena  to  be  next  described,  we  may  refer 
to  the  subject  of  Will.  Volition,  although  frequently  leading 
to  action,  is  not  to  be  confounded  therewith  ;  in  fact,  in  its 
highest  form  it  is  probably  more  often  associated  with  the 
inhibition  rather  than  the  initiation  of  movement.  Conse- 
quently the  restless  activity  and  the  sudden  impulsive  acts  of 
feeble-minded  children  are  by  no  means  an  indication  of  will 
power,  but  rather  the  reverse.  Will  is  always  accompanied  by 
mental  effort,  and  of  this,  to  any  great  extent,  the  mentally  defi- 


Nervous  and  Mental  Characteristics  of  Amentia  1 1 1 

cient  are  often  incapable.  Their  inability  to  keep  an  ideal  or 
course  of  action  steadfastly  in  front  of  them  leads  to  the  absence 
of  fixity  of  purpose  or  capacity  to  offer  serious  resistance  to  the 
will  of  others.  Consequently  many  of  them  readily  fall  in  with 
suggestions  which  are  made  to  them,  and  easily  become  the  prey 
and  tools  of  designing  and  evil-disposed  persons. 


""  Motor  Processes. 

Mind  is  manifested  as  motion,  and  mental  and  motor  activities 
run  on  parallel  lines.  The  motor  functions  of  the  body,  as  seen 
in  movement  and  speech,  are  generally  similar  in  quantity  and 
quality  to  the  more  purely  psychological  processes  just  described, 
and,  since  they  are  capable  of  more  ready  investigation,  they  often 
afford  valuable  indications  as  to  the  nature  and  working  of  the 
mind.  This  relationship  has  been  ably  pointed  out  by  Dr. 
Francis  Warner,*  and  to  this  author  we  are  indebted  for  much 
valuable  information  regarding  anomalies  of  motor  function, 
or,  as  he  terms  them,  "  abnormal  nerve  signs,"  in  the  mentally 
defective. 

Movement. — The  simplest  form  of  movement  is,  in  all  prob- 
ability, the  result  of  explosions  within  the  motor  ganglion  cells 
taking  place  in  consequence  of  their  own  inherent  instability. 
Such  movement  is  spontaneous,  and  is  seen  in  the  spreading 
of  the  fingers  and  toes  of  the  young  infant  (the  "  microkinesis  " 
of  Warner),  later  in  the  inarticulate  babblings  which  denote  the 
first  activity  of  the  motor  cells  concerned  in  speech.  Presently, 
as  a  result  of  the  laying  down  of  pathways  within  the  cerebral 
mass,  thejTiotor^cells  require  two  connexions.  One  of  these 
brings  them  into  relatioiL3vith  the  sensory^ areas  of  the  brain, 
the  QtIieF~withjthe  higher_levels  concerned  in  ideation  and 
volition.     As  a  resuTTof  the  former  of  these  connexions,  the 


simple  spontaneous  movements  become  so  modified  and  con- 
trolled by  the  quantity  and  quality  of  the  incoming  sensations 
as  to  be  perfectly  adapted  to  them.  We  then  have  a  co-ordinated 
movement,  in  which  an  optimum  result  takes  place  with  a 
minimum  expenditure.     When  this  result  has  been  attained,  and 

*  Francis  Warner,  "Anatomy  of  Movement,"  "Mental  Faculty,"  and 
numerous  other  writings. 


Mental  Deficiency 

<a  well-worn  pathway  established  between  sensory  and  motor 
areas,  the  appropriate  movement  is  readily  called  forth  upon 
the  presentment  of  its  customary  stimulus,  producing  a  :i^ex 

/  co-ordinated  action. 

««»-.„. 

The  new-born  child  comes  into  the  world  with  some  of  these 
channels  already  laid  down,  so  that  it  is  capabJe  of  so-called 
instinctive  or  hereditary  movements,  such  as  sucking  and  crying. 
Many  of  the  ordinary  reflex  movements  are  the  result  of  spinal 
rather  than  cerebral  action. 

The  second  connexion,  which  links  up  the  motor  cells  with  those 
portions  of  the  brain  concerned  with  the  intellectual  processes, 
brings  the  motor  functions  under  the  influence  of  the  will,  and  so 
makes  volitional  action  possible.  Such  action  is  always  pre- 
ceded by  an  idea  of  the  motion  to  be  performed  (motor  idea). 
The  nature  of  this  volitional  action,  however,  will  be  different 
according  as  other  intellectual  associations  act  as  a  drag  or  not 
upon  immediate  response.  In  the  simplest  and  lowest  type  of 
mind  an  immediate  response  follows  the  presentment  of  the 
idea,  and  the  action  is  impulsive.  Such  may  take  place 
almost  with  the  rapidity  of  a  reflex  act  ;  indeed,  by  constant 
repetition  the  motor  idea  to  an  action  of  this  kind  may  be  sub- 
conscious, and  the  action  truly  reflex.  On  the  other  hand,  the 
motor  idea  may  call  up  other  associates,  so  that  deliberation 
intervenes  to  delay  or  inhibit  the  natural  tendency  to  immediate 
action.  After  a  longer  or  shorter  period  of  deliberation,  in  which 
the  pros  and  cons  are  carefully  passed  in  review,  a  choice  is 
made,  and  finally  the  highest  type  of  action — a  deliberate,  pur- 
poseful manifestation  of  will — results. 

I  We  thus  see  that  in  aments  various  anomalies  of  movement 
•  may  occur  as  a  result  of  their  imperfection  of  development.  The 
metabolism  or  excitability  of  the  motor  ganglion  cells  may  be 
abnormal,  and  the  quantity  of  movement  defective  or  excessive. 
Sensations  may  be  imperfect  or  distorted,  or  the  connexions 
between  sensory  and  motor  areas  faulty,  leading  to  defects  in  the 
quality  of  movement  or  inco-ordination.  The  connexions  be- 
tween sensory  and  motor  centres  which  are  normally  laid  down 
at  birth  may  be  lacking,  producing  a  diminution  or  absence  of 
the  instinctive  movements — a  condition  which  is  by  no  means 
infrequent  in  idiocy.     On  the  volitional  side  response  may  occur 


Nervous  and  Mental  Characteristics  of  Amentia  1 1  3 

immediately  upon  presentment  of  the  idea,  and  impulsive  action 
of  this  kind  is  very  characteristic  of  many  aments.  On  the 
other  hand,  response  may  be  tardy,  not  because  of  the  inter- 
vention of  deliberation,  but  because  the  cerebral  cells  generally 
are  lethargic  and  unexcitable,  and  the  connexion  between  voli- 
tional and  motor  centres  a  comparatively  untrodden  pathway  ; 
and  this  kind  of  slothful  action  is  characteristic  of  another  type 
of  aments.  Finally,  anomalies  of  movement  may  occur  in 
consequence  of  gross  lesions  or  disease  of  the  cerebro-spinal  axis. 
We  may  now  consider  the  chief  of  these  anomalies  of  the  motor 
functions  somewhat  more  in  detail. 

Deficient  Movement. — In  a  considerable  number  of  aments 
movement  Js  deficient  in  quantity,  and  this  is  the  result  of  a 
generally  diminished,  excitability  of  the  nerve  cells.  The  con- 
dition is  most  common  in  the  severest  grade,  but  it  is  also  seen 
in  the  imbeciles  and  feeble-minded.  In  the  most  pronounced 
cases  it  is  obvious  from  birth,  and  the  child  never  cries,  sucks, 
or  looks  about  him  like  an  ordinary  child  ;  in  the  milder  forms 
these  instinctive  movements  are  present,  but  the  child  is  back- 
ward in  his  first  attempts  at  sitting  up,  standing,  and  walking, 
whilst  speech  is  very  much  delayed.  The  appearance  of  such 
children  is  usually  characteristic  ;  the  facewears  a  dull,  heavyT^ 
vacuous  expression,  and  there  are  many  indications  of  want  of 
muscular  tone.  In  the  temporal  and  masseter  muscles  this 
often  shows  itself  by  dropping  of  the  lower  jaw  and  a  persistently 
open  mouth.  The  general  balance  of  the  body  is  feeble,  and  when 
the  child  walks,  he  does  so  with  a  slothful  clumsiness.  If  told 
to  follow  an  object  with  his  eyes,  he  either  makes  no  response 
or  turns  his  whole  head  round  in  a  slow  and  laboured  manner. 
His  arms  are  listlessly  ^extended  to  command,  but  the  fingers 
and  hands  hang  flabbily  down,  and  the  whole  arm  very  soon 
drops  to  the  side.  His  whole  appearance  and  behaviour  are 
indicative  of  cerebral  and  spinal  inertia. 

Excessive  Movement. — In  another  type  of  aments  all  movement 
is  in  excess,  and  the  condition  is  one  of  chattering,  ceaseless 
activity.  This  also  is  noticeable  soon  after  birth,  and  the 
remark  is  often  made  by  the  parents  that  the  child  "  never 
sleeps."  This,  of  course,  is  not  reaUy  the  case  ;  for  although 
these  children  do  not  have  regular  long  periods  of  sleep  like 

8 


114  Mental  Deficiency 


ordinary  children,  or  even  ordinary  idiots,  there  is  no  doubt 
that  they  do  have  brief  but  frequent  snatches.  There  is  equally 
no  doubt,  however,  that  their  sleep  is  very  light  and  readily 
disturbed.  This  condition  is  the  antithesis  of  the  one  just 
described,  and  is  due  fr>  hyper -fy^^jf^g^l^pity  of  nervous  tissue. 
For  some  time  after  birth  it  is  manifested  as  an  excess  of  spon- 
taneous movement,  but,  as  the  motor  cells  acquire  connexions 
with  sensory  and  ideational  areas,  this  type  of  movement  alters, 
being  replaced  by  actions  of  a  higher  order.  Of  these  there  are 
three  chief  forms — namely,  ideo-motor  repetitive  actions  of  sub-'' 
conscious  type  ;  ideo-motor  repetitive  actions  of  conscious  type  ; 
and  impulsive  volitional  actions.  It  is  to  be  remarked  that, 
although  these  varieties  of  excessive  movement  are  very  common 
in  amentia,  they  are  not  characteristic  of  that  condition,  but  may 
occur  in  a  merely  neurotic  child.  Most  of  these  forms  of  excessive 
movement  are  accompanied  by  a  diminished  capacity  for  sus- 
tained attention,  and  this  is  well  seen  in  the  restless  ament  whose 
attention  is  so  distracted  by  every  sight,  sound,  or  feeling  reach- 
ing his  sensorium  that  steady  continuous  work  becomes  an 
impossibility. 

In  a  considerable  number  of  aments  excessive  action  is  chiefly 
pronounced  in  certain  groups  of  muscles,  and,  by  being  constantly 
repeated,  the  movements  acquire  an  automatic  and  subconscious 
character.  They  are  then  popularly  known  as  tricks  or 
habits.  The  most  frequent  of  these  are  spasmodic  frowning 
and  knitting  of  the  eyebrows  (which  may  be  symmetrical  or 
unilateral),  grinning,  smiling,  and  grimacing  ;  nodding  and 
shaking  of  the  head  ;  shrugging  of  one  or  both  shoulders  ;  open- 
ing and  shutting  of  the  hands,  and  swaying  of  the  body  ;  biting 
the  nails,  sucking  the  thumb,  and  many  qthers  of  like  character. 
The  characteristic  of  these  movements  is  that,  at  first  irregular, 
they  subsequently  tend  to  be  repeated  at  more  or  less  regular 
intervals,  and  are  particularly  marked  when  the  child  is  in  the 
presence  of  strangers  and  conscious  that  he  is  being  observed ; 
further,  unlike  the  irregular,  purposeless  movements  of  chorea, 
they  are  definite  co-ordinated  acts.  Originally  it  is  probable 
that  many  of  them  had  a  purpose  ;  for  instance,  I  have  some- 
times traced  the  repeated  shaking  of  the  head,  which  is  very 
commonly  seen  in  neurotic  children,  to  the  presence  of  long. 


Nervous  and  Mental  Characteristics  of  Amentia  1 15 

straggling  hair  hanging  in  front  of  the  eyes.  The  frequent  repeti- 
tion of  the  act  produces  in  time  a  kind  of  obsession,  and  this  leads 
to  its  automatic  unconscious  performance  when  the  original 
cause  has  been  removed.  In  aments  it  often  lasts  throughout 
life. 

Closely  related  to  these  automatic  actions  are  others  of  a 
somewhat  higher  character,  inasmuch  as  they  are  always  volun- 
tarily performed.  Dr.  John  Thomson*  enumerates  the  chief 
of  these  as  pica,  or  dirt-eating,  sucking  the  tongue,  thumb,  etc., 
biting  the  nails,  head-rolling,  head-banging,  rocking  and  swaying 
movements  of  the  body,  and  masturbation.  Dr.  Thomson  says 
that  '*  the  normal  act  causes  little  pleasure  to  the  healthy  child, 
whilst  its  morbid  counterpart  has  an  extraordinary  fascination  for 
the  children  who  practise  it.  .  .  .  The  essential  character  which 
serves  at  once  to  distinguish  these  habits  from  certain  motor 
neuroses  [e.g.,  spasmus  nutans  and  habit  spasm),  which  some  of 
them  superficially  resemble,  is  their  deliherateness.  The  child's 
will  is  implicated  ;  and  what  he  does  is  done  intentionally — at 
first,  at  least — because  he  likes  doing  it.  They  have  a  strong 
tendency  to  occur  when  the  patient  is  feeling  dull  and  not  being 
interested  by  his  surroundings.  They  are  almost  always  stopped 
when  the  child's  attention  is  taken  up  with  anything  that 
interests  him." 

Finally,  another  type  of  excessive  movement  is  seen  in  the 
impulsive  volitional  actions  which  are  of  such  frequent  occurrence 
in  certain  mental  defectives.  With  these  persons,  an  idea  is  no 
sooner  piesented  than  it  is  acted  upon,  quite  regardless  of  right 
or  wrong  or  possible  consequences.  Many  of  them  belong  to 
the  milder  degrees  of  amentia,  and  some  are  by  no  means  un- 
intelligent ;  but  their  whole  life  is  actuated,  not  by  intelligence, 
but  by  impulse.  The  essential  basis  seems  to  be  an  undue 
motor  excitability,  and  the  defective  deliberation  and  "control 
allow  this  to  have  free  play.  They  comprise  the  "  unstable  " 
type  of  aments,  of  whom  more  will  be  said  in  subsequent  chapters. 

Inco-ordiuate  Morcuioit. — Co-ordination,  in  the  wide  mean- 
ingoTthe  term,  requires  a  scries  of  motor  pvp1ng^ion<i  which  arp. 
regular  intime,  degree,  and  sjequenre,  as  well  as  their  harmonious 

*  John  Thomson,  "On  Certain  So-called  'Bad  Habits'  in  Children," 
Archives  of  Pediatrics,  April,  1907. 

8—2 


ii6  Mental  Deficiency 

adaptation  to  the  various  sensory  stimuli  concerned  in  tlje  move- 
ment performed,  particularly  those  coming  from  the  muscles. 
It  IS  therefore  dependent  upon  perfectly  working  sensory,  "co! 
missural,  and  motor  mechanisms  ;  but  even  where  these  exist, 
as  in  the  normal  child,  perfect  co-ordination  is  only  attainedLby 
constant  practice. 

In  persons  suffering  from  even  the  mildest  degree  of  amentia, 
co-ordination  is  often  acquired  with  difficulty,  and  remains  im- 
perfect ;  and  although  many  of  them  may  learn  to  use  their 
hands  with  a  considerable  amount  of  dexterity,,  the  balance  and 
movement  of  the  body  often  continue  clumsy  and  ungainly. 
It  is  frequently  years  before  the  mentally  defective  child  manages 
to  lace  his  boots,  button  his  clothes,  or  manipulate  his  spoon  at 
table.  Even  the  best  of  them  (with  a  few  remarkable  exceptions) 
\  rarely  attain  to  the  precision  and  neatness  of  movement  of  which 
an  ordinary  well-trained  child  is  capable. 

In  the  lower  degrees  the  defect  is  still  more  marked,  and  many 
imbeciles  experience  the  greatest  difficulty  in  picking  up  a  pin 
or  a  coin,  and  are  incapable  of  any  but  the  coarsest  movements. 
Ireland  remarks  that  considerably  more  imbeciles  than. normal 
people  are  ambidextrous  ;  but  I  think  it  is  not  that  both  hands 
are  used  equally  well,  but  rather  equally  badly,  and  i  should 
prefer  to  say  that  they  were  adextrous.  Many  of  their  defects 
of  speech  are  due  to  imperfectmtiscwiar  co-ordination. 

An  extremely  delicate  test  of  the  degree  of  control  over  mus- 
cular action  is  afforded  by  the  "  transfer  "  and  "  imitation  " 
movements  of  Dr.  Warner.  In  performing  imitation  movements, 
the  child  stands  a  little  distance  in  front  of  the  observer,  who 
performs  a  series  of  extensions,  flexions,  and  other  movements 
with  his  own  arm,  forearm,  hand,  and  finally  individual  digits, 
each  of  which  the  child  must  imitate  as  it  is  performed.  In 
the  transfer  movements  the  child  stands  with  closed  eyes  and 
extended  hands.  The  observer  then  performs  passive  movements 
upon  the  digits,  etc.,  of  one  limb  of  the  child,  who  is  required  to 
make  corresponding  movements  with  the  other.  Dr.  Warner  tells 
me  that  he  considers  these  tests  to  be  extremely  delicate,  and 
that  even  in  a  healthy  person  slight  imperfections  may  be 
observed  as  the  result  of  fatigue. 

Finally,  it   may  be  remarked   that  anomalies  of  movement 


Nervous  and  Mental  Characteristics  of  Amentia  1 17 

due  to  localized  or  general  disease  of  the  brain  are  not  uncommon 
in  aments.  The  chief  of  these  are  n^^stagmus,  athetosis,  epilepti- 
iorin  and  epileptic  convulsions,  and  chorea  ;  but  they  do  not  differ 
from  similar  affections  in  the  mentally  sound. 


Speech. 

The  speech_of  aments  is  a  matter  of  considerable  interest  and 
irnportance.  for  several  reasons.  In  the  first  place,  defects  of 
speech  are  very  frequent,  and  their  examination  affords  a  means 
by  which  certain  sensory,  associative,  and  motor  functions  may 
be  conveniently  tested  and"  recorde^f^  Further,  quite  apart  from 
its  mere  mechanism,  the  language  of  these  persons  is  one  of  the 
most  valuable  means  weTiave  of  gauging  their  stock  of  ideas  and 
the~generarcapacity'~and  natuie  of  Lheir  inteTTects;  whilst  in  the 
milder  degrees  the  training  of  speech,  if  conducted  upon  scientific 
principles,  and  after  a  careful  study  of  the  needs  of  the  individual, 
is  a  very  important  means  of  improving  sensory  and  motor 
functions,  and  regulating  mental  action  generally. 

True  speech  is  not  merely  the  ability  to  utter  articulate  sounds  : 
it  is~lhe  faculty  of  using  words  to  express  thoughts  ;  and  before 
this  can  take  place  certain  conditions  must  be  fulfilled.  These 
are,  firstly,  the  power  to  hear  sounds  ;  secondly,  a  conscious 
recognition  of ^  the  object  or  idea  for  which  the  sound  heard 
is  the  symbol  ;  thirdly,  an  ability  to  reproduce  the  sound 
as  the  expression  of  the  same  object  or  idea.  It  is  thus  seen 
that  the  faculty  of  speech  is  composed  of  an  afferent  pathway 
(norfHally  auditory,  although  exceptionally  other  sensory  channels 
may  serve  instead,  as  in  lip  reading),  with  its  prolongation  tp  a 
higher  conscious  station ;  of  a  connexion  between  this  conscious 
station  and  the  motor  speech  centre  ;  and  thence  an  efferent  path- 
way  to  the  muscles  concerned  in  phonation  and  articulation.  In 
addition,  there  is  good  reason  for  thinking  that  a  more  direct 
and  subconscious  connexion  exists  between  the  sensory  and  motor 
centres.  The  nervous  mechanism  concerned  in  speech  may 
therefore  be  represented  iDy' the  capital  letter  A,  in  which  the 
side-limbs  denote  the  afferent  and  efferent  paths  respectively  to 
and  from  consciousness,  and  the  cross-piece  the  shorter  sub- 
conscious connexion  between  the  sensory  and  motor  stations. 


ii8  Mental  Deficiency 

In  the  normal  child  sounds  are  differentiated  inthe  early 
months  of  life,  but  it  is  not  until  he  is  nearly  a  year  old_that  he 
begins  to  associate  words  with  objects  and  ideas,  and  to  under- 
stand what  is  said  to  him.  At  this^age  he  has  still  little  command 
over  the  motor  speech  centre,  the  first  evidence  of  activity  in 
which  consists  of  cooing  and  babbling  interjections  of  spon- 
taneous origin  similar  to  the  incessant  small  movements  of  fingers 
and  toes.  Presently,  however,  owing  to  the  faculty  of  imitation, 
these  irregular' sounds  become  co-ordinated  into  copies  of  those 
he  hears,  and  very  soon  after  this  the  child  acquires  the  power 
of  expressing  his  simple  thoughts  and  wants  by  articulate  speech. 
After  this  progress  is  usually  rapid,  and  during  the  third  year 
the  child  may  possess  a  vocabulary  of  several  hundred  words. 

In  the  ament  defects  of  speech  are  exceedingly  common, 
probably  being  present  to  some  extent  jn-'fnllj^three-quarters 
of  aU  cases.  In  tji^se  persons  the  advent  of  speech  js  pearly 
alwa^s^°^layed,  the  first  indication  of  spontaneity  in  the 
motor  cells,  which  normally  appears  during  the  third  or  fourth 
month,'  not  being  noticed  until  much  later.  It  may  be  five, 
six,  or  even  more  years  before  the  mentally  deficient  child  gives 
utterance  to  a  definite  word  as  the  expression  of  an  idea.  In 
the  severest  grades  of  mental  defect  the  faculty  is  never  de- 
veloped, and  the  majority  of  idiots  are  incapable  of  articulating 
a  single  word.  Others  of  this  degree  can  say  a  lew  mono- 
syllables,  such  as  "  man,"  "  cat,"  but  none  of  them  are  capable 
of  forming  sentences.  In  the  imbecile  speech  is  usually  present, 
and  he  is  ablejto  understand  and  speak  short  sentences  ;  but^his 
vocabulary  is  small,  and  his  utterance  often  almost  unintelligible. 
In  the  feeble-minded  degree,  imperfections  of  utterance  tend  to  be 
somewhat  less,  and  the  vocabulary  considerably  more  extensive  ; 
but  these  persons  are  usually  neither  capable  of  forming  nor 
understanding  a  sentence  at  all  complicated  in  its  construction. 

It  is  thus^  seen  that  on  the  whole  there  is  a  tolerably  close 
relationship  between  the  capacity  for  speech  and  the  degree  of 
mental  defect,  and  this  led  Esquirol  to  suggest  the  use  of  this 
faculty  as  a  means  of  classification.  But  to  this  there  are  many 
exceptions  :  some  quite  low-grade  imbeciles  are  possessed  of 
exceedingly  good  articulation  and  fluent  speech,  whilst  a  small 
number  of  the  feeble-minded  are  limited  in  their  utterance  to  a 


Nervous  and  Mental  Characteristics  of  Amentia  1 19 

few  words,  and  even  these  may  be  almost  unintelligible.  The 
remarkable  genius  of  Earlswood  Asylum,  of  whom  a  description 
will  be  given  in  a  subsequent  chapter,  is  an  excellent  example 
of  this  latter  class.  It  is  true  that  those  imbeciles  whose  speech 
is  so  fluent  often  have  little  or  even  no  idea  of  the  meaning  of 
the  poetry  or  sentences  they  so  glibly  repeat,  and  it  is  quite  open 
to  question  whether  their  articulatory  capacity  properly  comes 
within  the  strict  meaning  of  the  term  "  speech."  But,  even 
apart 'from  this,  I  am  of  opinion  that  there  is  no  such  constant 
relationship  between  \veaTth  of  ideas  and  capacity  of  expressing 
them  as  would  justify  us  in  accepting  speech  as  a  means  of  differ- 
entiation ;  and  the  physician  must  be  upon  his  guard  against 
"judging  of  the  degree  of  mental  deficiency  by  the  amount  of 
speech. 

In  cases  where  there  is  no  deafness,  and  speech  is  markedly 
deficient,  it  is  highly  probable  that  some  degree  of  defect  is 
present,  and  "delayed  speech  is  often  one  of  the  first  signs  to 
attract  the  parents'  attention,  and  causes  professional  advice  to 
be  sought  ;  but,  as  gn  indication^f  the  amount  of  defect,  expres- 
sion and  general  beha\'iour  may  be  of  far  more  importance  than 
speech. 

Defects  of  speech  may  be  due  to  anomalies  of  the  sensory, 
motor,  or_  mtellectuaT  "(association)  pathways  ;  l^ut  in  most 
cases  It  IS  th^lwo  la L Lei  Wlifcli'are-^chi^fly  at  fault ._  Sensory 
defects  may  be  auditory,  causing  an  imperfect  perception  of 
sounds  ;  or  they  may  concern  the  tactile  and  muscular  sensations 
coming  from  the  tongue  and  lips  during  the  act  of  articulation. 
It  has  already  been  remarked  that  the  range  and  delicacy  of  the 
sensorium  of  the  anient  is  often  diminished,  and  in  a  few  more 
or  less  actual  deafness  is  present.  I  do  not  think,  however,  that 
imperfections  of  hearing  play  a  very  important  part  in  the 
defective  speech  of  these  persons. 

Anomalies  of  the  motor  mechanism  are  much  more  frequent, 
and  tBesecomprise  imperfections  of  the  cortical  speech  centre, 
or  of  the  end  organs  concerned  in  the  production  of  voice  and 
speech.  With  regard  to  central  defects,  pure  motor  aphasia  is 
rare  ;  but  one  boy,  who  was  under  my  care  for  several  years, 
was  a  perfect  example  of  this  condition.  In  this  case  there  was 
at  times  considerable  inattention  ;  but  the  boy  had  no  loss  of 


I20  Mental  Deficiency 

hearing,  and  could  understand  and  obey  commands  perfectly 
well.  He  could  also  make  grunting  and  other  inarticulate 
noises,  but  the  only  approach  to  a  word  which  we  could  get  him 
to  say  after  years  of  training  was  "  Cuckoo. "  This  case,  however, 
was  one  of  secondary  and  not  primary  amentia,  and  resulted  from 
an  attack  of  encephalitis  in  the  early  months  of  life.  Another 
and  much  more  common  cortical  anomaly  is  \he.  want  of 
co-ordination  which  results  in  stuttering  and  ^stammering. 
Peripheral  deficiencies  are  exceedingly  numerous,  and  the  whole 
character  ot  the  voice  and  speech  may  be  profoundly  altered  by 
deformities  of  the  tongue,  lips,  teeth,  and  palate,  as  well  as  by 
enlarged  tonsils  and  adenoids.  I  doubt,  however,  whether  short- 
ness of  the  fraenum  linguae  ("  tongue-tied  ")  can  ever  be  con- 
sidered a  cause  of  delayed  or  even  imperfect  utterance. 

Defects  of  pronunciation  are  exceedingly  common  in  even  the 
mildest  grades  of  amentia,  and  are  generally  attributable  to  im- 
perfect co-ordination.  ,  It  is  not  usual  to  find  any  marked  impair- 


ment of  the  vowel  sound^  the  chief  imperfections  being  noticed  in 
the  consonants  ("  lalling  "j.  The  pTiysiological  alphabet  of  Wyllie* 
forms  the  basis  upon"^which  many  interesting  observations  have 
been  made  in  recent  years,  amongst  which  those  of  Dr.  Henry 
Ashbyf  and  Dr.  LapageJ  deserve  particular  mention.  To  this 
latter  inquirer  we  are  indebted  for  a  most  careful  research  into 
the  consonantal  defects  of  the  feeble-minded  child,  and  the 
following  table  is  to  a  great  extent  compiled  from  his  work. 
In  this  table  the  consonants  are  placed  in  the  ojrder  in  which 
Dr.  Lapage  found  them  most  frequently  defective,  the  sounds 
commonly  substituted  being  also  shown  (see  Table  XIII.). 

It  is  of  interest  to  compare  this  defective  power  of  pronuncia- 
tion, which  is  so  common  in  aments,  with  the  marked  aptitudes 
in  this  respect  of  some  of  the  lowest  savages.  Darwin,  in  his 
"  Voyage  of  the  Beagle,"  relates  that  the  Fuegians  "  could 
repeat  with  perfect  correctness  each  word  in  any  sentence  we 
addressed  to  them,  and  they  remembered  such  words  for  some 
time.  .  .  .  All  savages  appear  to  possess,  to  an  uncommon 
degree,  this  power  of  mimicry.  I  was  told  of  the  same  ludicrous 
habit  aniong'Tile'  Caffres  ;  the  Australians,  likewise,  have  long 

*  Wyllie,  "  Disorders  of  Speech,"  1904. 

t  Ashby,   "  Speech  Defects  in  Mentally  Deficient  Children,"    Medical 
Chronicle,  October,  1903. 
X  I.apage,  op.  cit. 


Nervous  and  Mental  Characteristics  of  Amentia  121 


been  notorious  for  being  able  to  imitate  and  describe  the  gait  of 
any  man,  so  that  he  may  be  recognized."  As  will  be  seen 
in  speaking  of  idiots  savants,  such  extraordinary  powers  are  occa- 
sionally present  in  aments  ;  but  they  are  the  exception,  and  not 
the  rule. 

The  disorders  of  speech  which  are  chiefly  due  to  commissural 
and  intellectual  defects  include  the  misapplication  of  words  and"* 
the  inability  to  recall  appropriate  words  ;  whilst  it  is  only  to  ]3e 
expected  that  where  ideas  are  few  the  vocabular}'  will  not  be' 

TABLE  XIII. 

CoNS£)NANTAL    DEFECTS. 


Consonant. 

Commonly 
replaced  by 

As  in 

/     I.  Th 

F  or  T 

Fumb,  tee/,  mou/,  /ank. 

2.  R 

Y  or  L 

Yabbit  or  /abbit,  pa//ot. 

3.  Y 

R  or  L 

/.ellow.                                     1 

Most 
frequently 
defective 

4.  s 

T  or  Ts 

Tissors,  /soap. 

• 

5.  G 

6.  Ng 

7.  Sh 

I) 
D 

Tsh  or  T 

Dun,  dod,  sutfar. 

String. 

Tsheep,  TshudSiT,  Tirt. 

8.   K 

T 

Tat,  /oat,  bla/. 

9.  V 

B 

jBelvet. 

,  10.  L 

Y 

Yeg,  rad. 

r  II.    F 

T 

Tottee. 

12.   Z 

Dse 

Nodse. 

13.  W 

M  (or 

Mindow. 

Less 
frequently 
defective' 

omitted) 

- 

14.  P 

15.  N 

16.  D 

T  or  D 

D 

T 

Dadev. 

Tose,  Fed,  Peddy. 

Toot,  la/. 

17.  T 

D 

Dee/. 

18.  M 

B 

Ub. 

^  19.  B 

P 

Pag. 

extensive.  The  enunciation  of  the  grown-up  ament  often  retains 
"muchjf  the  character  of  childhood,  whilst  a  general  brain  inertia 
(sometimes,  however,  a  timidity  under  examination)  causes  speech  ^ 
to  be  slurred,  hesitating,  indistinct,  and  at  times  almost  unin- 
telligible. As  Max  Miiller  remarks,  correct  and.,  distinct  speec^ 
requires  a  definite  mental  effort,  and  of  this  many  aments  are 
incapable. 

In  some  aments  the  condition  known  as  coprolalia,  or 
"  filthy  speecH7''  exists.  This  is  a  more  or  less  suddeiToutBurst 
of  language  of  the  most  vile  and  disgusting  character,  and  it  is 


122  Mental  Deficiency 

remarkable  that  it  often  occurs  in  persons  brought  up  amid 
every  refinement.  It  is  usually  accompanied  by  a  general  state 
of  mental  excitement,  for  which,  however,  no  cause^m^y  be  dis- 
coverable, and  it  has  considerable  analogy  to  the  motor  convul- 
sions of  the  epileptic.     It  is  also  common  in  the  insane. 

Finally,  mention  rriust  be  made  of  that  curious  speech  dis- 
turbance known  as  echolalia.  In  this  condition,  although  the 
child  can,  and  often  does,  use  words  to  express  his  ideas,  any 
question  put  to  him  is  followed,  not  by  a  reply,  but  by  its  repetiT.., 
tion.  Sometimes,  after  repeating  the  question  once  or  twice, 
the  child  will  answer  it ;  but  in  other  cases  he  is  merely  repetitive, 
and  often  copies  the  tone  and  manner  of  the  questioner  with 
remarkable  exactitude.  I  recently  saw  a  mentally  defective 
child  with  this  peculiarity,  whose  parents  assured  me  he  could 
speak  quite  sensibly,  and  yet  to  my  questions  the  only  words 
I  could  get  out  of  him  were,  ''  What  is  your  name  ?"  ''  Who  is 
this  ?"  (pointing  to  his  mother),  ''  Shut  the  door,"  and  similar 
repetitions  of  every  question  or  command.  This  condition  is 
not  very  common,  and  is  somewhat  difficult  to  explain.  I  ain 
disposed  to  think  that  it  may  be  due  to  the  child's  consciousness 
being  so  swamped  or  occupied  (by  emotions  of  fright  or  anxiety 
in  some  cases  at  the  presence  of  a  stranger  or  unaccustomed  sur- 
roundings) that  auditory  sounds  only  reach  a  subconscious  motor 
idea  centre,  and  are  thence  immediately  translated  into  speech. 
There  is,  jn  fact,  a  short-circuiting  of  the  nerve  current.  This 
conartion,  as  far  as  I  am  aware,  does  not  occur  in  persons  of 
normal  mental  development,  although  it  is,  of  course,  by  no^means 
uncommon  for  a  person  to  speak  who  is  totally  unconscious  of 
his  surroundings.  Many  normal  children,  whilst  busily  engaged 
in  some  occupation,  will  repeat  words  which  are  pronounced  near 
them,  without  seemingly  understanding  the  words  or  being  at  all 
aware  of  the  fact  that  they  have  copied  them.  It  is  presumably 
by  a  similar  subconscious  mechanism  that  echolalia  occurs. 

It  has  already  been. mentioned  that  some  aments  have  an 
extraordinary  laculty  for  repeating  sounds  with  extreme  accu- 
racy. This  ranges  from  the  humming  of  a  tune  to  the  repetition 
of  poetry  or  sentences  in  an  entirely  unknown  tongue.  The 
subject  will  be  again  alluded  to  under  Idiots  Savants,  but  it  is 
worthy  of  passing  mention  in  this  place. 


CHAPTER  VIU 

FEEBLE-MINDEDNESS    IN    CHILDREN 
(MENTALLY  DEFECTIVE  CHILDREN) 

The  term  feeble-mindedness  is  applied  to  the  mildest  of  the  three 
degrees  of  amentia.  In  the  extent  of  their  deficiency  there  is  no 
difference  between  the  feeble-minded  child  and  adult  ;  but  as  the 
former  are  subject  to  the  provisions  of  a  special  Act  of  Parlia- 
ment, which  brings  them  within  the  jurisdiction  of  the  education 
authority,  it  is  necessary  to  consider  them  separately.  In  this 
chapter,  therefore,  we  shall  consider  feeble-minded  persons  below 
the  age  of  sixteen  years,  or,  as  they  are  designated  in  the  Act, 
mentally  defective  children  ;  those  over  this  age  will  be  described 
as  "  feeble-minded  adults  "  subsequently. 

After  the  passing  of  the  Education  Act  of  1876,  making  attend- 
ance at  public  elementary  or  other  schools  compulsory,  attention 
began  to  be  directed  to  the  educational  needs  of  the  mentally 
deficient.  It  became  apparent  that  a  group  of  children  existed 
who  were  so  far  defective  that  they  could  not  be  satisfactorily 
taught  in  the  ordinary  public  schools,  but  who  were  not  suffi- 
ciently defective  to  be  certified  as  imbeciles  or  idiots  under  the 
Idiots  Act  of  1886.  Many  particulars  regarding  this  class  were 
brought  to  light  through  the  inquiries  of  medical  men  and 
scientific  and  philanthropic  societies,  amongst  whom  special  men- 
tion must  be  made  of  Dr.  Francis  Warner,  Dr.  Fletcher  Beach,  Dr. 
Hack  Tuke,  and  Dr.  Shuttleworth ;  the  British  Association,  the 
British  Medical  Association,  and  the  Charity  Organization  Society. 
The  researches  of  Dr.  Francis  Warner  in  particular  were  of  the 
most  painstaking  nature,  arid  were  based  upon  the  examination 
of  100,000  school-children.*     As   a   result   of   these  inquiries, 

*  See  "  Report  on  the  Scientific  Study  of  the  Mental  and  Physical  Con- 
ditions of  Childhood,"  Parkes  Museum,  1895  ;  also  "  Report  on  the  Feeble- 
Minded,"  etc.,  C.O.S.,  1892. 

123 


I  24  Mental  Deficiency 

a  Departmental  Committee  of  the  Board  of  Education  was 
appointed  in  1896  to  consider  and  report  upon  the  question. 

This  Committee  presented  its  report  in  1898.*  It  recognized 
that  a  number  of  children  existed  in  public  elementary  schools 
who,  in  their  mental  capacity,  were  intermediate  between  the 
ordinary  "  dullards  "  and  certifiable  imbeciles,  and  it  estimated 
the  proportion  of  this  class  as  approximately  i  per  cent,  of  the 
elementary  school  population.  Its  inquiries  showed  that  these 
children  were  incapable  of  receiving  proper  benefit  from  the 
ordinary  instruction  in  these  schools,  but  that  they  were  capable 
of  receiving  considerable  benefit  from  the  individual  attention 
and  instruction  given  in  special  classes — that,  in  fact,  under  such 
conditions  there  was  a  fair  prospect  of  many  of  them  being 
enabled  to  take  their  place  in  the  world.  It  considered  that  these 
defective  children  would  suffer  by  association  with  imbeciles, 
and  should  not,  therefore,  be  educated  with  them ;  and  it  recom- 
mended that  special  classes  and  schools  should  be  established 
to  meet  their  requirements.  This  report  led  to  the  passing  in 
the  following  year  of  the  Defective  and  Epileptic  Children 
(Education)  Act. 

This  Act  (62  and  63  Vict.,  ch.  32,  1899)  was  the  first  legal 
recognition  in  this  country  of  the  mildest  or  feeble-minded  grade 
of  amentia.  It  defines  the  class  as  those  children  who,  "not  being 
imbecile,  and  not  being  merely  dull  and  backward,  are  defective — 
that  is  to  say,  by  reason  of  mental  [or  physical)  defect  are  incapable 
of  receiving  proper  benefit  from  the  instruction  in  the  ordinary 
public  elementary  schools,  but  are  not  incapable  by  reason  of  such 
defect  of  receiving  benefit  from  instruction  in  such  special  classes 
and  schools  as  are  in  this  Act  mentioned.'' 

This  Act,  therefore,  clearly  differentiates  between  the  mildest 
degree  of  amentia  and  the  more  pronounced  affection  of  imbecility, 
and  although  it  does  not  apply  the  term  "  feeble-minded  "  to 
this  class,  the  condition  it  defines  is  clearly  identical  with  that 
to  which  this  term  has  for  long  been  specifically  applied  in  this 
country.  Mentally  defective  children  are,  in  fact,  the  juvenile 
feeble-minded.  The  Act  permits  the  local  education  authorities 
to  establish  special  classes  and  schools  for  the  mental  defectives 

*  "  Report  of  the  Departmental  Committee  on  Defective  and  Epileptic 
Children,"  1898. 


Feeble-Mindedness  in   Children  125 

within  their  district,  and  where  such  are  estabhshed  attendance 
is  compulsory  up  to  the  age  of  sixteen  years,  instead  of  fourteen, 
as  in  the  ordinary  schools.  Unfortunately,  owing  to  its  permis- 
sive and  not  obligatory  nature,  the  Act  still  remains  a  dead  letter 
in  many  parts  of  the  country  ;  but  since  it  has  been  adopted  by 
the  whole  of  London,  as  well  as  by  over  twenty  of  the  largest 
towns  of  England,  the  education  of  mentally  defective  children 
may  now  be  said  to  have  become  an  integral  and  important  part 
of  the  educational  system  of  the  nation. 

The  investigations  instituted  by  the  Royal  Commission  of 
1904  throw  further  light  upon  the  number  and  condition  of  this 
class  ;  but,  whilst  agreeing  in  several  respects  with  the  conclu- 
sions previously  arrived  at,  they  differ  on  two  important  points. 

Firstly,  as  will  be  seen  immediately,  the  i  per.  cent  estimate  is 
found  to  be  somewhat  too  high  ;  secondly,  a  more  extended 
experience  of  these  children  shows  that  the  views  which  were 
formerly  held  as  to  the  amount  of  amelioration  under  training, 
and  their  possibility  of  becoming  self-supporting  citizens,  are  too 
optimistic. 

Numerical  Incidence. 

As  the  result  of  a  careful  analysis  of  the  reports  of  the 
Royal  Commission,  I  estimate  that  the  mean  average  incidence  of 
mentally  defective  children  throughout  England  and  Wales  is 
073  per  cent,  of  the  children  on  the  registers  of  public  elementary 
schools.  This  number  is  somewhat  lower  than  previous  esti- 
mates, but  as  these  inquiries,  in  addition  to  being  more  recent, 
were  obtained  under  more  favourable  methods  of  examination, 
and  also  embrace  a  larger  variety  of  districts,  I  am  inclined  to 
give  preference  to  them.  These  figures,  however,  do  not  include 
defective  children  who,  for  various  reasons,  are  not  attending 
elementary  schools,  and  if  these  be  included  the  total  number  of 
mental  defectives  is  raised  to  0-83  per  cent,  of  the  school  popula- 
tion. I  calculate  that  in  the  whole  of  England  and  Wales  the 
approximate  total  of  these  children  is  50,665. 

But,  as  will  be  seen  from  the  accompanying  Table  XIV. ,  show- 
ing the  percentages  in  the  respective  districts  investigated,  this  is 
the  mean  average  of  two  widely  divergent  extremes.  In  Durham, 
for  instance,  the  percentage  is  only  0*24,  whilst  in  Dublin  it  is 


126 


Mental  Deficiency 


as  high  as  i'85,  and  it  becomes  necessary  to  consider  the  cause 
of  these  extreme  variations. 

Much  of  the  difference  is  clearly  due  to  the  fact  that  the 
incidence  of  mental  abnormality  in  general  (insanity  and  amentia) 
is  not  uniform  throughout  the  country,  but  is  subject  to  very 
considerable  variations  from  causes  which  at  present  are  not 
fully  understood.  This  we  shall  not  consider.  But  there  are 
smaller  variations  which  appear  to  be  decidedly  dependent  upon 


TABLE     XIV. 

Showing  the  Percentage  of  Mentally  Defective  Children  to  the 
Public  Elementary  vSchool  Population  in  Certain  Districts 
investigated  by  the  Royal  Commission  of  1904. 


District. 

Percentage 

Urban  . .          . .   - 

'  Manchester 
Birmingham     . . 

Hull 

Glasgow 

DubUn  

Belfast 

I -20 
. .      I  -03 
. .     0-30 
. .     074 
..      1-85 
..     0-50 

r  Stoke-on-Trent 
Industrial        . .   -    Durham 

i  Cork 

•  •     0-59 
. .     0-24 
..     0-3S 

Mixed  industrial  /  Nottinghamshire 
and  agricultural  \  Carmarthenshire 

. .     0-66 
. .     076 

s^^icultural    .  .    - 

"  Somersetshire  .  . 
Wiltshire 
Lincolnshire     .  . 
Carnarvonshire 
Galway 

. .     o-6i 
..     0-55 
. .     0-96 
. .     0-47 
..      1-33 

sociological  and  other  influences,  and  since  these  relate,  not  to 
mental  abnormality  in  general,  but  to  the  particular  class  with 
which  we  are  now  dealing,  they  must  be  referred  to. 

Relative  Incidence  in  Town  and  Country. — It  has  been 
shown  that  although  amentia  as  a  whole  is  more  prevalent' 
in  rural,  and  insanity  in  urban,  districts,  and  the  number  of, 
idiots  and  imbeciles  in  the  country  far  exceeds  that  in  the 
towns,  nevertheless  the  incidence  di  mentally  defective  children 
is  decidedly  greater  in  the  towns  than  in  the  country.  In 
view  of  the  fact  that  these  children  differ  only  in  degree,  and 
not  in  kind,  from  the  idiots  and  imbeciles,  this  is  in  itself  singular  ; 
but  it  becomes  even  more  so  when  it  is  found  that  the  feeble- 


Feeble-Mindedness  in   Children  127 

minded  adult,  who  is  simply  the  mentally  defective  child  grown 
up,  is  not  more  prevalent  in  town  than  in  country,  but  is  actually 
less  so. 

What,  then,  is  the  cause  of  this  excess  of  mentally  defective 
children  in  a  town  as  compared  with  a  country  environment  ? 

The  answer  which  at  once  suggests  itself  is  that  the  many 
adverse  factors  of  the  environment  of  our  towns,  the  improper 
feeding,  the  faulty  ventilation,  the  overcrowding,  and,  in  fact, 
slum  life  generally,  are  responsible  for  the  excess  ;  and  since  a 
history  of  morbid  heredity  is  often  very  difficult  to  obtain  in 
these  cases,  the  (perhaps  not  unnatural)  conclusion  has  followed 
that  environment  plays  a  very  important  part  in  the  production 
of  this  mild  degree  of  amentia.  That  feeble-mindedness  may 
occasionally  so  result  I  do  not  deny,  but  I  believe  that  the 
increased  incidence  of  mental  defectives  in  towns  is  to  a  great 
extent  apparent  only,  and  is  due  to  the  inclusion  of  a  number 
of  children  who  are  not  aments  at  all. 

In  examining  school-children  in  both  town  and  country,  I" 
have  often  been  struck  by  the  fact  that  the  ill-washed,  ill-clad, 
and  ill-fed — in  short,  the  victims  of  faulty  environment — were 
not  as  a  rule  the  mental  defectives.  In  fact,  such  children  were 
often  alert  and  quick-witted  beyond  the  average,  although 
probably  by  no  means  keen  on  book-learning.  This  fact  led 
me  somewhat  to  discount  environment  as  being  a  frequent  cause 
of  amentia.  Next,  in  examining  certified  mental  defectives  in 
special  schools,  I  discovered  a  proportion  of  cases  which  I  had 
no  hesitation  in  saying  were  not  aments  at  all,  but  merely  suffer- 
ing from  backwardness,  and  this  caused  me  to  make  some 
inquiries  as  to  the  number  of  such  children  who  recovered. 

Now,  the  essence  of  mental  defect  is  that  it  is  incurable,  and 
by  no  ''  S£ecialJ^^education.  lioweyer  elaboratg^^^^  ^  case  of 
"aiTfetrtiaTbe'raiseS  to  the^'iigrrrnrf '^t^t^rfa rd .  Some  defect  must 
always  rernain,  and  upon  this  fact  all  authorities  are  agreed. 
When,  therefore,  it  is  found  that  a  proportion  of  the  urban 
defectives  attending  special  schools  are  returned  as  cured  to  the 
ordinary  schools,  it  is  clear  that  an  error  of  diagnosis  has  been 
made,  and  that  they  were  not  defectives.  The  proportion  so 
returned  varies  very  much  in  different  towns,  and  in  many  the 
special  classes  have  not  been  established  sufficiently  long  to  form 


128  Mental  Deficiency 

a  reliable  test.  The  following  is  the  percentage  (of  the  admissions) 
of  '*  mentally  defective  "  children  who  have  so  far  been  returned 
cured  to  ordinary  schools  in  some  towns  in  which  I  made  inquiries  : 
Birkenhead,  6  per  cent.  ;  Bradford,  15  per  cent. ;  Bristol,  3  per 
cent.  ;  Derby,  5  per  cent. ;  Leeds,  2  per  cent.  ;  Leicester,  20  per 
cent.  ;  Liverpool,  4  per  cent.  ;  London,  10  per  cent.  ;  Nottingham, 
10  per  cent. ;  Plymouth,  8  per  cent.  ;  Sheffield,  4  per  cent.  I 
think  these  figures  show  conclusively  that  a  varying,  and  in 
some  cases  considerable,  proportion  of  the  town  defectives  are 
not  aments  at  all.  On  this  point  I  may  quote  the  opinions  of 
two  physicians  who  have  had  large  experience  of  these  children. 
Dr.  Evan  Powell,  of  Nottingham,  writes  :  "  I  agree  with  you 
that  a  large  number  of  so-called  defectives  are  in  reality  not  so, 
but  are  merely  suffering  from  temporary  arrest."  And  Dr.  Ralph 
Crowley,  of  Bradford,  writes  :  *'  I  have  no  hesitation  in  saying 
that,  where  many  go  back,  the  reason  is  to  be  found  in  the  fact 
that  the  children  in  the  first  place  belonged  to  the  '  merely  dull 
and  backward  group.' " 

I  shall  have  occasion  again  to  refer  to  these  cases  of  delayed 
development,  which  simulate  mental  defect,  in  speaking  of 
diagnosis  ;  but  I  have  thought  it  well  to  allude  to  them  here  for 
the  reason  that  the  neglect  to  distinguish  them  may  cause 
totally  erroneous  views  as  to  the  increased  prevalence  of  mental 
deficiency  in  towns,  as  well  as  of  its  cause  and  its  possibility  of 
cure.  It  seems  to  me  probable  that  the  real  incidence  of  defect  in 
town  is  not  much,  if  any,  greater  than  in  country  districts. 

With  regard  to  the  social  status  of  these  children  there  is 
little  to  be  said.  The  labouring  classes  have  no  monopoly  of 
morbid  heredity,  and,  although  I  am  unable  to  give  any  actual 
figures,  my  general  impression  is  that  mental  defect  is  just  as 
prevalent  amongst  the  upper  as  the  lower  classes  of  this  country. 

Willij"egurd  to  sex,  there  is  a  considerable  preponderance  of 
males,  the  relative  proportion  of  boys  to  girls  being  practically  as 
three  to  two. 

Description. 

Mentally  defective  or  feeble-minded  children  differ  greatly  in 
the  degree  of  their  deficiency.  The  lower  members  of  the  class 
closely  approximate  to,  and  cannot  be  distinctly  separated  from, 


Feeble-Mindedness  in  Children  129 

the  imbeciles.  The  higher  members,  on  the  other  hand,  are 
but  little  removed  from  the  merely  dull  and  backward  of  the 
normal  population.  It  is  therefore  clear  that  no  general  descrip- 
tion can  be  given  which  would  be  applicable  to  every  mentally 
defective  child  ;  but  the  following  are  the  chief  characteristics 
of  the  class.  Illustrations  of  the  milder  degrees  are  shown  in 
Plate  III. 

Physical  Condition. — A  small  proportion  of  children  suffering 

from  mental  defect  would  pa^g  mngfpr  a«i  iinrmai  irJ-Rftir  VJ^a^- 

7i6i>ls  rested  upon  irispeciion  t5niy  •;  but  §Ti5!rcases'are  exceptional , 
and  the  majority  present  unmistakable  anomalies  of  bodily 
structure  or  function,  as  well  as  of  mental  development. 

Anatomical  anomalies,  or  so-called  stigmata  of  degeneracy, 
are  usually  neither  so  plentiful  nor  pronounced  in  the  feeble- 
minded child  as  in  the  imbecile  or  idiot  ;  nevertheless  Dr.  Lapage, 
as  a  result  of  his  examination  of  200  children,  found  such  to 
occur  in  no  less  than  90*5  per  cent,  of  the  total  number  examined. 
TKi^e~fe"Ct5"i^ere  usuair^^  Ift  rSrHbrnaHoh ,  and  in  23 73  per  cent.*  -^ 
were  triple.  In  my  experience  the  cranium  is  the  most  common^ — 
site  of  defects,  and  i  believe  it  to  De  abnormal  either  in  shape  or^ 
size,  asymmetrical,  bossed,  or  ridged,  in  fully  half  of  these 
children.  When  the  child  first  comes  to  school,  and  between 
the  ages  of  seven  and  ten  or  twelve  years,  the  maximum  circum- 
ference is  usually  about  half  an  inch  less  than  that  of  -a  normal 
child  of  corresponding  age  and  sex  ;  but  this  discrepancy  becomes 
more  and  more  marked,  and  by  the  fourteenth  or  sixteenth  year 
the  difference  may  be  as  much  as  an  inch,  or  even  more.  Next 
in  frequency  to  the  cranium,  anomalies  of  the  palate  are  found ; 
whilst  malformations  of  the  external  ear  and  of  the  eye  and  its 
appendages  occur  a  little  less  often. 

Inquiries  will  nearly  always  show  that  in  these  children 
dentition,  standing,  walking,  and  speaking  have  been  abnor- 
mally delayed.  It  may  be  four,  five,  or  even  six  years  before  the 
child  says  a  word.  This  retardation  continues  with  advance  - 
in  years,  so  that  at  every  period  of  its  school-life  the  mentally 
defective  child  compares  unfavourably  in  its  bodily  growth  and 
acquirements  with  the  one  of  normal  intellect.  Moreover,  the 
bodily  functions  are  often  imperfectly  performed  :  the  circula-  > 
tion  is  feeble,  so  that  chilblains  and  sores  are  frequent  in  cold 

9      ■ 


130  Mental  Deficiency 

>^ 
weather ;    assimilation    is    defective,    consequently    the    child 

remains  thin  and  ill-nourished  ;  the  vitality  generally  is  dimin- 
ished, and  catarrhs  and  ill-health  are  exceedingly  common.  It 
was  ascertained  by  Dr.  Ashby  that  the  children  in  special  schools 
at  Manchester  averaged  2  to  4  inches  less  in  height  and  3  to 
12  pounds  less  in  weight  than  the  normal.  To  some  extent 
this  may  be  due  to  the  nature  of  the  environment  in  these  cases. 
As  already  stated,  the  home  conditions  of  the  feeble-minded  are 
often  very  faulty,  and  I  have  usually  found  that  the  defectives 
in  the  country  are  sturdier  and  of  better  physique  than  are  those 
in  the  towns  ;  but  this  is  not  the  full  explanation,  for  the  same 
applies  to  normal  children,  and,  whatever  their  situation,  mentally 
defective  children  compare  unfavourably  with  their  mentally 
sound  fellows. 

Abnormalities  of  Nerve  Action  are  very  frequent.  In  some 
children  there  is  a  general  diminution  of  activity,  and  such  are 
heavy,  stolid,  tardy  in  response,  and  laboured  in  all  their  move- 


ments. —In  others  the  reverse  is  the  case,  and  all  movement  is 
in  excess.     Such  children  cannot  sit  or  stand  still  ;  they  are 
distracted  from  their  task  by  every  little  thing  around  them, 
and  they  are  often  full  of  "  tricks  "  and  "  habits."    Co-ordination  ^ 
of  movement  is  slowly  and  laboriously^  acquired.     The  making 
of  pothooks  and  hangers  presents  difficulties  unknown  to  the 
ordinary  child,  and  paper-folding,  card -pricking,  and  the  simple 
kindergarten  occupations   are  in  the  first  instance  performed 
with  a  laborious  clumsiness.     Many  of  the  milder  defectives,  as 
a  result  of  special  training,  do  learn  to  use  their  hands  extremely 
well,   but   even  these  rarely  acquire  the   degree  of  dexterity  / 
attainable  by  an  ordinary  child  who  has  been  similarly  trained. 
In   some   instances    speech    is    accompanied   by    "  spreading  " 
action,  as  seen  in  corrugation  of  the  forehead,  grinning,  and  at 
times  twitching  of  the  whole  body. 

The  net  result  of  these  anomalies  of  nerve  action  is  a  pecu- 
liarity of  balance  and  movement  and  of  physiognomical  expres-  ^ 
sion  which  is  exceedingly  characteristic  of  the  class,  and  which 
frequently  enables  the  expert  to  detect  mental  deficiency  at  a 
glance.  The  expression  varies  from  a  look  of  heavy,  immobile 
stupidity  and  vacuity,  which  is  chiefly  seen  in  those  lacking  in 
action,  to  a  general  restlessness  and  inattention  to  the  subject 


Feeble-Mindedness  in  Children  i  3 1 

in  hand,  often  accompanied  by  spasmodic  twitches,  tricks,  and 
habits,  which  is  characteristic  of  those  in  whom  action  is  excessive- 
Spccc/i,  as  well  as  being  late  in  making  its  appearance,  is 
defective  in  fully  one-third  of  these  children.  It  is  very  rarely 
lacking  entirely,  although  the  speech  of  some  children,  before 
training,  is  so  imperfect  as  to  be  quite  unintelligible  to  a  stranger. 
The  chief  defects  consist  of  a  thickness  and  indistinctness  of 
utterance,  an  imperfect  articulation  of  consonants,  and  (rarely) 
stammering  and  stuttering.  The  former  of  these  conditions  is 
partly  attributable  to  abnormaT  configuration  of  fhe  palatClip^ 
jaws,  or  pharynx,  and  partly  to  a  geneial  bi'cllii  uiettTa  and 
inability  or  unwillingness  to  make  the  effort  necessary  for  distinct 
enunciation.  The  consonantal  defects  are  due  to  similar  causes 
plus  a  want  of  co-ordination.  It  may  be  remarked  that*  in- 
ability to  pronounce,  not  one  in  particular,  hut  man^onsona.nts  J^ 


k  vp.ry  rnmmnnly  indicative  of  mental  deficieacv. 

Mental  Condition. — Sensation. — In  a  small  proportion  of 
these  children  sensation  is  imperfect  by  reason  of  disease  or 
anomalies  of  the  peripheral  or  central  organs  ;  but  on  the  whole 
serious  sensory  defects  are  not  a  prominent  feature  of  the  feeble-^ 
minded  degree  of  amentia.  Defects  of  hearing  (which  are 
generally  due  to  disease  of  the  middle  ear)  are  present  in  about 
8  per  cent.,  and  defects  of  vision  in  about  15  per  cent.,  of  cases. 
Colour-blindness,  although  in  many  cases  seemingly  present,  is 
not  in  reality  any  more  common  than  in  ordinary  children. 

But  there  is  a  great  difference  in  the  educability  of  the  percep-  ^ 
tive  faculties  of  feeble-minded  children.  The  ordinary  healthy 
child  possesses  an  initiative  and  enterprise  which  brings  him 
into  daily  contact  with  sights,  sounds,  and  impressions  of  every 
description.  His  faculties  of  attention  and  curiosity  cause  him 
to  observe,  smell,  and  handle  everything  he  meets,  and  in  conse- 
quence the  range  and  delicacy  of  his  sensorium  soon  becomes 
very  considerable.  The  feeble-minded  child  is  defective  in  many 
of  these  qualities  ;  consequently  the  development  of  his  sen- 
sorium has  to  be  aided  and  encouraged  by  special  means,  and 
until  this  has  been  done  his  power  of  sensory  discrimination  is 
decidedly  inferior  to  that  of  the  normal  child  of  similar  age.  I 
have  frequently  observed  that,  upon  their  admission  to  a  special 
school,  the  sensory  capacity  of  defective  children  is  compara- 

9-2 


/ 


132  Mental  Deficiency 

lively  obtuse,  and  that  they  have  little  ability  to  discriminate 
between  sensory  impressions  of  the  same  order,  but  of  slightly 
differing  intensity.  Under  suitable  training  much  of  this  is 
remedied,  and  the  sensory  functions  of  many  of  the  milder  types 
who  have  been  thus  trained  does  not  seem  to  be  much  inferior 
to  the  normal.  But  the  lower  types  are  lacking  in  this  power 
to  develop,  and  in  them  the  most  persistent  special  training 
fails  to  bring  the  sensorium  up  to  the  normal  level.  In  this 
latter  class  the  organic  sensations  of  pain,  cold,  hunger,  and 
discomfort  are  also  somewhat  obtuse,  but  these  do  not  appear 
to  be  so  much  affected  as  do  the  special  senses. 

Attention. — In  the  lethargic,  inert  type  of  feeble-mindedness 
there  is  a  defect  of  spontaneous  attention  ;  but  this  is  never  so 
marked  in  this  degree  as  in  the  more  serious  grades  of  amentia. 
The  general  stir  and  excitement  aroused  by  a  visitor  is  much 
more  pronounced  in  the  special  school  than  in  the  imbecile 
ward.  On  the  other  hand,  active  or  voluntary  attention  is 
commonly  in  defect,  both  with  regard  to  its  intensity  and  its 
duration.  The  most  trifling  thing  serves  to  distract  these 
children  from  their  occupation,  so  that  even  where  the  attention 
is  readily  gained,  it  is  with  difficulty  held.  Many  of  them  become 
capable  of  pursuing  a  congenial  task  with  a  certain  amount  of 
patience,  but  the  majority  have  neither  power  of  conceiitration 
nor  will  sufficient  to  be  capable  of  sustained  mental  effort 
against  inclination  or  interposed  obstacles.  They  must  go  with, 
for  they  cannot  fight  against,  the  stream  ;  and  this  lack  of  will- 
power and  driving  force  is  one  of  the  most  distinguishing  charac- 
teristics of  aments  at  all  ages. 

School-teachers  often  complain  of  the  lack  of  memory  of  these 
children,  and  if  this  faculty  is  to  be  judged  by  their  inability 
to  remember  items  of  scholastic  knowledge,  there  would  certainly 
appear  to  be  a  decided  deficiency.  Some  of  them  have  very  great 
difficulty  in  connecting  a  word  with  a  thing,  or  in  recognizing  a 
printed  character  or  numeral  as  the  symbol  of  a  concrete  object 
or  number  of  objects.  It  is  the  same  with  colours  :  many  can 
match  colours  perfectly  well,  thus  proving  that  their  colour- 
sense  is  not  defective,  and  yet  they  may  constantly  confuse  the- 
names  of  colours.  It  is  probably  this  which  has  given  rise  to 
the  impression  that  colour-blindness  is  common  amongst  them. 


Feeble-Mindedness  in  Children  133 

It  is  not  to  be  expected  that  such  a  child  would  remember 
historical  or  geographical  data,  but  the  defect  seems  to  be  rather 
one  of  association  and  comprehension  of  the  abstract  than  of 
memory  proper.  In  the  tenacity  of  their  memory  for  things 
which  are  really  understood,  I  have  been  unable  to  satisfy 
myself  that  feeble-minded  are  at  all  inferior  to  normal  children, 
and  many  of  them  retain  items  of  knowledge  which  have  been 
demonstrated  by  concrete  examples,  as  in  object-lessons,  remark- 
ably well. 

As  a  class,  mentally  defective  children  are  imitators  rather 
than  originators.  They  may  faithfully  reproduce,  but  they 
rarely  create,  and  their  faculty  for  evolvijig__new  ideas — imagina-  , 
Hon — is  decidedly  lacking.  But  some  of  them  evince  consider- 
able cunning  in  the  commission  of  misdeeds,  as  well  as  no  little 
ingenuity  in  the  invention  of  lies  to  escape  the  consequences  ; 
and  in  many  there  is  abundant  evidence  of  the  existence  of  the 
day-dreams  and  flights  of  fancy  which  figure  so  largely  in  the 
mental  life  of  the  normal  child.  I  have  often  seen  them  look 
forward  with  delight  to  the  approaching  Christmas-tree,  and 
several  of  my  little  patients  have  taken  me  into  their  confidence 
in  recounting  their  ambition  to  be  a  judge,  a  soldier,  sailor, 
policeman,  or  engine-driver.  Nevertheless,  the  fact  remains 
that  in  constructive  imagination  and  inventiveness  there  is 
usually  a  considerable  defect. 

Control  is  very  feebly  developed  in  these  children,  and  action 
is  always  along  the  line  of  least  resistance.  Volition  is  by  no 
means  absent,  but  their  behaviour  is  more  often  the  result  of 
sudden  desires  and  impulses  than  of  deliberate  purpose.  They 
are  capable  of  such  simple  feelings  as  pleasure,  pain,  fear, 
astonishment,  anger,  surprise,  and  the  like  ;  but  their  erngtions, 
like  their  sensations,  are  usually  weak  and  evanescent.  ^JJ^h^- 
are  rarely  stirred  by  hate,  incITgnation,  anguish,  awe,  or  a  con- 
"§£lQusness  of  the  sublime.  They  are  readily  amused  by  any- 
thing ridiculous  and  touched  by  anything  pathetic  ;  but  they 
have  little  real  sense  of  humour. 

All  of  them  are  lacking  in  the  logical,  and  most  of  them  in  the 
aesthetic,  sense.  In  a  small  proportion  there  is,  in  addition,  a 
marked  deficiency  or  perversion  of  the  moral  sense,  and  such 
will  lie,  pilfer,  and  generally  misconduct  themselves,  without  the 


134  Mental  Deficiency 

slightest  compunction.  Some  of  this  type  are  exceedingly 
cunning,  and  a  few  are  guilty  of  acts  of  marked  cruelty  to  other 
children  or  to  dumb  animals.  They  will  also  make  utterly  un- 
founded accusations  with  a  considerable  amount  of  detail  and 
appearance  of  truth.  On  the  other  hand,  there  are  many  who 
are  contented,  obedient,  well-behaved,  and  affectionate,  and 
they  may  even  possess  a  tolerable  conception  of  their  moral  and 
religious  obligations.  Some  are  capable  of  understanding  and 
being  influenced  by  simple  theological  doctrines,  but  on  the 
whole  the  religious  sentiment  in  these  children  is  of  a  decidedly 
poor  order. 

Scholastic  Acquirements. 

All  these  children  are  greatly  improved  by  suitable  training, 
but  their  developmental  capacity  and  response  to  education 
vary  enormously.  On  this  account  it  is  convenient  to  divide 
them  into  three  grades. 

The  first  grade  is  composed  of  children  who  make  tolerable 
progress  in  elementary  school  knowledge.  They  are  capable  of 
writing  a  simple  letter,  they  can  read  children's  books,  and  they 
can  perform  simple  arithmetical  exercises  mentally,  as  well  as 
the  first  four  rules  on  paper.  They  have  a  knowledge  of  money 
values,  and  they  can  be  trusted  with  simple  commissions.  Their 
handiwork  is  often  extremely  good,  and  they  do  little  drawings, 
brush-work,  cutting-out,  basket  and  wicker  work,  rug-making, 
and  the  like,  with  a  dexterity  which  is  often  surprising.  They 
have  some  common  sense,  but  they  lack  resource  and  judgment, 
and  often  initiative.  ^CM-^^t*Y  ^    ^ /**^^ 

The  second  grade  fall  considerably  behind  the  former  in 
purely  scholastic  attainments,  and  also,  although  not  to  the 
same  extent,  in  handicraft.  They  are  rarely  capable  of  mental, 
and  seldom  of  paper,  arithmetic,  and  their  reading  and  writing 
ability  extends  no  further  than  simple  words  of  one  syllable. 
Some  are  even  unable  to  do  this. 

They  can  perform  the  same  kind  of  manual  work,  but  the 
result  is  not  nearly  so  good,  and  they  require  more  constant 
stimulation  as  well  as  much  closer  supervision.  They  have 
decidedly  less  general  intelligence. 

The  third  grade  form  a  connecting  link  with  the  imbeciles, 


Feeble-Mindedness  in  Children  135 

from  whom,  indeed,  they  are  but  Httle  removed.  The  improve- 
ment effected  by  the  special  school  is  limited  to  the  develop- 
mentof  some  capacity  for  manual  work  under  supervision,  and 
to  the  formation  of  habits  of  obedience,  tidiness,  and  regularity. 
Their  scholastic  acquirements  are  practically  nil. 

As  a  concrete  example  of  the  difference  between  mentally 
defective  and  normal  school-children,  I  may  give  the  following 
brief  account  of  the  pupils  attending  a  typical  "  special  "  school 
under  the  London  County  Council. 

This  school*  contains  over  sixty  defective  boys  and  girls,  who 
are  divided  into  three  separate  classes,  each  under  a  mistress. 
In  the  lowest  class  the  average  age  of  the  children  is  from  eight 
to  nine  years,  the  youngest  being  seven  and  the  oldest  about 
twelve  years.  In  age,  therefore,  they  correspond  approximately 
to  normal  Standard  II.,  in  which  the  school-work  consists  of — 
Reading  equivalent  to  ^Esop's  "Fables."  Writing:  transcrip- 
tion and  dictation  equal  to  the  same.  Arithmetic  :  tables  up  to 
12  X  12  ;  pence  table  ;  compound  addition,  subtraction,  multi- 
plication, and  division  ;  four  simple  rules  and  problems  intro- 
ducing two  or  more  rules  at  one  time.  Drawing :  simple  free- 
hand ;  use  of  ruler  and  set-square.  Geography.  History.  Object- 
lessons  in  animal  and  vegetable  life  and  simple  science. 

The  work  actually  done  by  the  defective  children  in  this  class 
consists  of  recognition  of  letters  of  the  alphabet  and  reading 
words  of  three  or  four  letters  ;  transcription  of  the  same  from 
a  blackboard  copy  ;  recognition  of  simple  numerals,  and  writing 
the  same  from  dictation  ;  simple  addition  up  to  ten  and  simple 
subtraction  of  single  figures.  None  are  capable  of  writing  from 
dictation,  and  all  sums  are  done  in  the  concrete  by  means  of 
beads  or  tablets.  In  addition,  the  children  are  taught  the  use 
of  the  ruler ;  they  learn  simple  paper  folding  and  cutting, 
brush-work,  and  rough  clay  modelling.  They  also  engage  in 
musical  drill  and  games. 

The  average  defective  child  takes  two  years  before  he  or 
she  becomes  proficient  enough  to  be  passed  out  of  this  class. 
Some  never  do  attain  to  this  proficiency,  although  they  may  be 
moved  up   on   account   of  their  size.     A  few   are  sufficiently 

*  Goodrich  Road  Special  School,  East  Dulwich,  S.E..  in  the  charge  of 
Miss  N.  Mumbrav. 


136  Mental  Deficiency 

advanced  to  be  transferred  after  six  months,  but  I  am  of  opinion 
that  the  majority  of  these  are  not  really  defective,  but  merely 
dull  and  backward. 

In  the  middle  class  the  average  age  is  from  ten  to  eleven, 
the  youngest  being  eight  and  the  oldest  sixteen  years.  It  thus 
corresponds  to  normal  Standard  IV.,  in  which  the  work  consists 
of — Reading  from  Geographical,  Historical,  and  Literary  Readers. 
Writing,  the  same,  with  short  essays  and  letter-writing. 
Arithmetic :  simple  exercises  in  money,  time,  weights  and 
measures  ;  simple  vulgar  and  decimal  fractions.  Geography, 
History,  Grammar,  Object-lessons,  and  Drawing,  all  more  ad- 
vanced. 

The  work  actually  done  in  this  class  is  reading  simple  words 
of  one  and  two  syllables  from  Infant  Reader  I.  ;  transcription 
and  dictation  in  simple  words  of  one  and  two  syllables  ;  addition, 
in  the  abstract,  of  simple  numbers  up  to  100  ;  subtraction  of 
tens  and  units  ;  simple  multiplication  and,  rarely,  simple  division 
by  one  figure.  The  occupations  consist  of  rather  more  advanced 
brush-work,  paper-folding  and  threading,  cutting  paper  in  the 
form  of  leaves  for  flower-making,  and  clay-modelling.  The 
average  time  spent  in  this  class  is  about  two  years. 

In  the  highest  class  the  average  age  is  twelve  years,  the 
youngest  being  ten  and  the  oldest  nearly  sixteen.  One-fourth 
of  the  pupils  are  over  thirteen.  They  thus  correspond  in  age 
with  Standards  VI.  and  VII.,  in  which  the  school-work  consists 
of — Reading  from  more  advanced  Literary,  Geographical,  and 
Historical  Readers.  Writing,  the  same,  with  short  original  essays 
on  geographical  and  historical  topics.  Arithmetic:  simple  and 
compound  practice  ;  problems  in  greatest  common  measure  and 
least  common  multiple  ;  the  first  four  rules  in  vulgar  and  decimal 
fractions.  Grammar,  with  analysis  and  parsing.  More  advanced 
History  and  Geography.  Geometry  and  Mo  del- drawing.  Elemen- 
tary lessons  in  Physics  and  Chemistry. 

The  work  done  by  this  class  consists  of  reading  and  writing 
equivalent  to  normal  Standard  II.  ;  compound  addition  and 
subtraction  up  to  1,000,  and  simple  multiplication  and  division. 
Excluding  a  few  children — who,  in  my  opinion,  are  not  really 
defective — it  may  be  said  that  the  scholastic  acquirements  of 
none  of  these  children  come  up  to  normal  Standard  II.     In 


Feeble-Mindedness  in  Children  137 

occupations  and  manual  work  they  are  decidedly  better,  and  a 
considerable  proportion  of  the  children  in  this  class  can  cut  out 
and  make  simple  artificial  flowers,  knit  rugs  and  weave  baskets, 
with  a  really  very  creditable  amount  of  dexterity,  which  re- 
dounds in  no  slight  measure  to  the  patient,  persevering,  and 
systematic  care  of  their  teacher. 

With  the  object  of  testing  their  capacity  for  attention,  memory, 
and  general  comprehension.  Miss  Mumbray  was  good  enough  to 
place  for  me  a  collection  of  twelve  small  articles,  such  as  a 
pencil,  tape,  bottle,  scissors,  etc.,  on  a  board,  and  let  the  children 
look  at  them  for  two  minutes.  The  board  was  then  removed, 
and  the  children  given  ten  minutes  in  which  to  write  down, 
either  in  words  or  graphically,  the  things  they  had  seen.  Out 
of  eighteen  competitors,  all  but  one  found  it  easier  to  draw  than 
to  write  the  names  of  the  objects  ;  five  children  remembered  the 
whole  twelve  articles,  four  remembered  eleven,  four  ten,  one 
nine,  one  eight,  two  seven,  and  one  only  five.  In  the  majority 
of  the  children  the  drawings  were  sufficiently  good  to  enable 
me  to  readily  recognize  the  several  objects  for  which  they  were 
intended,  whilst  some  were  really  excellent. 

Such  are  the  chief  abilities  and  disabilities  of  mentally  defective 
children.  They  differ,  however,  not  only  in  the  degree  of  their 
deficiency,  but  also  in  their  temperament,  disposition,  and  general 
behaviour.  In  fact,  they  possess  individuality  just  as  do  normal 
children,  although  this  is  not,  as  a  rule,  a  pronounced  and  domi- 
n'atmg^eature  untrTifter  puberty.  Moreover,  there  are  certain 
readily  recognizable  clinical  types  of  these  children,  just  as  there 
are  of  amen ts  in  general,  whilst  superadded  complications  are  not 
uncojnmon.  The  great  majority  suffer  from  primary  amentia, 
and  although  most  of  these  are  of  the  simple  variety,  between 
5  and  10  per  cent,  are  microcephalics,  about  2  or  3  per  cent, 
macrocephalics,  and  about  the  same  number  are  of  the  Mon- 
golian variety.  In  probably  about  10  to  15  per  cent,  of  these 
children  the  amentia  is  of  the  secondary  form,  most  of  them 
being-^f  the  vascular  or  post-febrile  varieties.  In  a  small  propor- 
tion of  these  some  degree  of  paresis  or  paralysis  is  present,  although 
*THIs  is  neither  so  prevalent  nor  so  severe  as  in  the  imbeciles 
and  idiots.  Another  small  proportion  are  cretins,  and  in  a  still 
smaller  number  there  is  evidence  of  syphilis.     Indications  of 


138  Mental  Deficiency 

rickets  are  not  uncommon,  whilst  in  about  10  per  cent,  of  cases 
the  feeble-mindedness  is  accompanied  by  epilepsy. 

But  whatever  the  particular  features  may  be,  there  is  one 
quality  which  characterizes  all  the  varieties  and  grades  of  these 
children,  and  that  is  their  inability  to  swim  against  the  stream, 
or  even  to  keep  their  heads  above  water,  without  the  assistance 
of  some  kindly  hand.  Whilst  the  ordinary  child  of  fourteen  or 
sixteen  years  has  not  only  a  considerable  knowledge  of  common 
things  and  events,  but  has  in  addition  acquired  notions  of 
qualities  and  conceptions  of  the  abstract  ;  whilst  he  has  developed 
the  faculty  of  comparing,  relating  and  judging  between  these 
conceptions,  and  of  tracing  a  connexion  between  cause  and 
effect ;  whilst  his  mind  now  enables  him  to  take  an  intelligent 
interest  in  his  daily  work,  and  allows  him  to  shape  plans  for  his 
future  ;  whilst,  in  short,  he  has  learned  to  put  away  childish 
things  and  has  become  capable  of  standing  alone — the  mentally 
defective  one  of  similar  age  is  still  happy  with  his  toys,  and  his 
whole  behaviour  and  conversation  still  indicate  the  infantile 
and  imperfect  character  of  his  mind.  Bodily  and  mentally  he 
is  always  in  arrears,  and  with  each  advancing  year  his  intellect  is 
left  farther  and  farther  behind  that  of  his  more  fortunate  fellow. 
His  special  training  has  done  much  for  him,  in  so  far  as  it  has 
inculcated  habits  of  regularity  and  conformity  to  the  will  of 
others  ;  further,  and  more  important,  because  it  has  converted 
him  from  a  useless,  and  often  dangerous,  member  of  society  into 
one  capable  of  some  amount  of  useful  work.  But  this  latter  can 
only  be  accomplished  under  supervision,  and  the  future  of  the 
feeble-minded  child,  as  he  passes  out  of  the  door  of  the  school 
for  the  last  time  into  the  great  world  beyond,  will  entirely  depend 
upon  how  thorough  and  careful  this  supervision  is. 


Diagnosis. 

Owing  to  the  Defective  Children  (Education  Act)  of  1899,  the 
diagnosis  of  this  condition  has  become  a  matter  of  considerable 
importance,  and  merits  our  special  attention.  It  may  be 
remarked  that  parents  sometimes  resent  a  diagnosis  of  mental 
defect,  and  the  examiner  may  be  called  upon  to  convince  a 
magistrate  of  its  accuracy,  in  order  to  enforce  attendance  at  a 


Feeble-Mindedness  in   Children  139 

special  school.  The  points  to  be  considered  are  :  (i)  The  family 
history  ;  (2)  the  personal  history  ;  and  (3)  the  present  state  of 
the  child      All  tnese  afe  ollrfiJDortance.  ~~      ~       """^       " 

With  regard  to  the  family  history,  we  have  seen  that  morbid  -L 
heredity  occurs  in  a  very  large  proportion  of  cases  ;  consequently 
its  presence  or  absence  in  any  given  child  is  an  indication  of 
value.  In  secondary  amentia,  however,  it  is  absent ;  and  evem 
where  existing  in  primary  cases,  it  must  be  remembered  that 
its  ascertainment  may  be  a  matter  of  very  great  difficulty.  In 
a  large  number  of  these  children  it  is  impossible  to  elicit  more 
than  the  most  fragmentary  family  history. 

In  investigating  the  personal  history,  inquiry  must  first  be 
made  as  to  whether  the  child's  mental  condition  is  of  recent  or 
long  standing.  In  most  cases  of  real  amentia  of  the  primary 
form,  it  will  be  found  that  some  dullness  or  peculiarity  has  been  "'^ 
"noticed  from  infancy,  and  that  there  has  been  a  general  retarda- 
tion of  physiological  development  (see  table  of  normal  develop- 
tnental  data,  p.  364).  Thus,  the  child  has  usually  been  back- 
ward in  cutting  his  teeth,  in  sitting  up,  in  attempting  to  stand; 
to  walk,  and  to  talk.  Delay  in  any  one  of  these  particulars  is 
of  little  importance,  for  the  range  of  normal  variation  is  very 
considerable  ;  but  delay  in  several  particulars,  provided  there  is 
an  absence  of  bodily  disease,  such  as  rickets,  etc.,  must  be  re- 
garded as  very  suspicious,  particularly  if  accompanied  by  a  neuro- 
pathic family  history.  Excejjtions  to^this  occur  in  cases  of 
delayed  primary  or  developmental  amentia,  in  which,  although 
morbid  heredity  may  be  present,  the  bodily  and  mental  condition 
of  the  child  are  often  normal  prior  to  the  advent  of  some  infan- 
tile illness  or  other  determining  factor. 

Most  cases  of  secondary  amentia  are  the  result  of  epilepsy,  or  of 
sorne'i>eiiuiis  lOxic  or  vascular  lesion  of  the  f^rain,  ^|  whirh  rqff^ 
willusually  be  a  clear  history.  Prior  to  this  the  child's  condition 
has  been  normal.  "      '""'^ 

Lastly,  the  child  himself  must  be  carefully  examined.  In 
doing  this  it  is  necessary  to  remember  that  many  children, 
whether  defective  or  sound,  are  nervous  an'd  ill-at-ease  under 
examination,  and  I  think  that  a  large  number  of  mistakes  in 
diagnosis  arise  from  the  inspector's  failure  to  gain  the  child's 
confidence.     This  should  be  the  first  concern,  and  the  whole 


140  Mental  Deficiency 

examination  must  be  quiet  and  deliberate,  but  kindly  and  free 
from  the  slightest  appearance  of  harshness.  The  child  must, 
of  course,  be  compared  with  his  compeers  in  age  and  social 
position. 

The  first  point  to  be  attended  to  is  the  physical  condition, 
paying  particular  attention  to  the  presence  or  otherwise  of 
illness  or 'disease,  anatomical  and  physiological  anomalies  or 
stigmata  of  degeneracy,  and  abnormal  nerve  signs.  The  state 
of  nutrition  and  the  general  physiognomy  must  also  be  carefully 
considered.  By  this  examination  indications  of  great  value  will 
be  forthcoming. 

Finally,  an  examination  must  be  made  of  the  child's  mentaL 
condition.  This  is  done  by  conversation,  careful  consideration 
of  his  manner,  behaviour,  general  conduct,  and  scholastic  and 
manual  ability.  It  is  impossible  to  lay  down  any  precise  rules, 
and  skill  in  diagnosis  can  only  be  gained  by  a  constant  association 
with  the  class  and  familiarity  with  their  characteristics  as  described 
in  the  preceding  pages.  There  is  no  single  psychological  test ;  but, 
as  we  have  seen,  the  chief  mental  peculiarities  of  these  children 
consist  in  a  lessened  range  and  acuteness  of  perception,  defect 
of  voluntary  attention,  crudity  and  childishness  of  ideas,  feeble 
reasoning  power  and  will,  and,  above  all,  deficient  "  common 
sense."  In  their  general  mental  development  and  capacity, 
especially  in  their  scholastic  attainments,  these  children  are 
markedly  behind  normal  ones  of  similar  age ;  although,  as  will 
presently  be  seen,  inability  to  progress  in  school  is  by  no  means 
diagnostic  of  mental  deficiency. 

Dr.  Warner  says  :   "  The  trained  observer  can  read  off  the 

physiognomy  of  the  individual  features   and  their  parts,   the 

facial  condition  and  eye  movements,  the  balance  of  the  head 

and  body,  etc.,  as  quickly  as  a  printed  line."    To  this  I  would  add 

4'  \-  that  the  expert  who  has  meanwhile  been  chatting  with  the  child, 

<:  by  the  time  he  has  proceeded  thus  far,  will  also  have  arrived  at 

'^    a  tolerably  accurate  estimate  of  the  degree  of  mental  capacity. 

vf      A  few  simple  tests  as  to  the  condition  of  the  special  senses,  the 

^      .  extent  of  memory,  the  power  of  reasoning,  and  the  scholastic 

^'  and  manual  attainments,  supplemented  by  particulars  from  the 

'^    teacher  or  parent  as  to  the  child's  habits  and  special  propensities, 

will  usually  provide  him  with  all  the  data  necessary  for  diagnosis. 


Feeble-Mindedness  in   Children  141 

The  Act  of  1899  requires  the  mentally  defective  child  to  be 
differentiated  from  the  "  merely  dull  and  backward  "  and  the 
imbecile.  It  may  therefore  be  useful  to  refer  to  the  chief  features 
of  these,  as  well  as  some  other  not  uncommon  conditions  of 
childhood,  which  may  more  or  less  closely  simulate  mental 
defect. 

Dull  and  Backward  Children. — The  "  dull  and  backward  " 
children  are  the  least  intellectually  gifted  members  of  the  normal 
population.  They  are  a  numerous  group,  but  their  proportion 
"varies  considerably  in  different  localities.  In  some  parts  of 
Somersetshire  I  found  them  to  the  extent  of  5  per  cent.,  in 
others  from  15  to  20  per  cent.,  of  the  school  population.  On  the 
whole,  I  think  they  are  commoner  in  country  than  in  urban 
districts.  These  children  fall  into  two  classes,  according  to 
whether  the  backwardness  is  confined  to  an  inability  to  acquire 
school  learning  only,  or  affects  the  whole  mental  faculties.  The 
former  class  are,  as  a  rule,  readily  distinguished  ;  but  in  the 
latter  diagnosis  may  be  a  matter  of  much  difficulty. 

As  an  example  of  the  dullards  or  dunces,  I  may  mention  the 
case  of  two  brothers,  aged  ten  and  twelve  respectively,  who, 
during  my  examination  of  a  large  country  school,  were  produced 
by  their  teacher  as  being  very  bad  cases  of  defect.  They  were 
both  in  Standard  II.,  and  my  examination  showed  that  they 
were  certainly  unequal  to  the  work.  But  I  soon  found  that  they 
had  a  very  good  knowledge  of  many  details  of  country  and 
farm  life — of  the  cows,  the  corn,  and  the  bird-nesting,  and  that 
they  were  by  no  means  backward  in  the  playground.  In  fact,  I 
had  little  difficulty  in  demonstrating  to  the  teacher  that,  although 
these  boys  could  hardly  do  the  simplest  sum,  and  could  only 
read  and  write  words  of  one  syllable,  yet  they  had  plenty  of 
common  sense,  and  were  by  no  means  mentally  deficient.  I 
have  frequently  found  this  failing  to  run  in  families,  and  in  a 
conversation  on  this  subject  with  an  intelligent  old  dominie  of 
a  country  school,  I  was  shown  an  excellent  example  in  three 
members  of  one  family  who  were  present  in  school  at  that  time, 
and  who  were  such  hopeless  dunces  that  their  attendance  seemed 
a  complete  waste  of  time.  My  informant  told  me  that  the 
father  of  these  children,  and  his  brothers  and  sisters,  had  all 
been  through  his  hands  in  their  turn,  and  they  were  just  the 


142  Mental  Deficiency 

same  ;  but  although  the  father  could  only  just  manage  to  scrawl 
his  name,  and  could  not  read  the  newspaper,  he  nevertheless 
worked  a  small  farm  with  complete  success.  Children  of  this 
kind  occur  in  the  towns  also,  and  although  they  cannot  or  will 
not  (I  think  it  is  a  little  of  both)  make  any  headway  with  their 
lessons,  they  are  as  sharp  as  needles  on  the  playground  and  in 
the  streets. 

It  is  possible  that  some  observers  would  consider  this  condition 
to  be  one  of  mild,  but  none  the  less  real,  mental  defect.  I  do 
not  think,  however,  that  they  should  be  so  classed.  Their  family 
history  is  generally  good  ;  they  are  sturdy,  well  grown,  free  from 
stigmata  of  degeneracy,  and  fully  up  to  the  average  in  every 
faculty  except  ability  to  acquire  book-learning.  It  seems  to  me 
that  they  are  perfectly  normal,  and  not  diseased  specimens  of 
mankind,  and  that  their  condition  is  simply  one  of  a  somewhat 
tardy  evolution  of  certain  faculties,  the  result  of  the  manner  of 
life  of  generations  of  ancestors.  ^'However  this  may  be,  I  am 
sure  that  inability  to  progress  at  school  is  not  necessarily  indica- 
tive of  mental  defect,  and  this  fact  the  medical  examiner  must 
keep  in  mind,  and  not  be  led  into  a  too  hasty  diagnosis  from  the 
school  report  only. 

But  in  a  certain  number  of  children  the  backwardness  is  not 
confined  to  school- work  ;  it  is  general.  These  children  are  not 
only  dunces  at  learning,  but  they  are  dull  at  games  and  in  out- 
door and  home  life  ;  in  fact,  their  whole  demeanour  and  behaviour 
are  characterized  by  a  more  or  less  dull  stolidity.  Here,  again,  I 
do  not  think  the  condition  is  necessarily  one  of  mental  defect  ; 
it  is  physiological,  and  not  pathological,  although  undoubtedly  . 
it  is  the  normal  in  its  lowest  mental  form.  It  is  these 
cases  which  cause  no  little  perplexity  to  the  medical  examiner, 
and  an  accurate  diagnosis  will  need  all  his  skill  and  experience. 
Perhaps  the  following  points  will  help  :  The  family  history  is 
decidedly  useful,  because  if  morbid  heredity  is  at  all  pronounced 
it  is  highly  probable  that  the  case  is  one  of  real  defect.  I  do  not 
think  that  information  as  to  the  previous  personal  history  is  of 
much  value,  for  most  of  these  generally  dull  and  backward  children 
resemble  the  real  defectives  in  having  been  in  arrears  all  along. 
A  careful  examination  of  the  child  is  of  the  greatest  importance. 
In  a  considerable  number  of  defectives  there  are  stigmata  of 


Feeble-Mindedness  in  Children 


H3 


degeneracy  and  abnormal  nerve  signs  ;  these  are  usualty  wanting 
in  the  cases  we  are  now  considering.  Further,  the  dull  and 
backward  are  usually  well  developed  and  of  good  nutrition — often, 
indeed,  fat  and  robust  ;  whilst  the  feeble-minded  are  usually  of 
defective  stature,  thin,  and  ill-nourished.  ^Finally,  and  most 
important,  the  child  must  be  carefully  questioned  in  such  a  ^^y 
00"-%^  to  reveal  his  general  knowledge  of  common  objects  and  his 
probable  course  of  action  under  everyday  circumstances.  By 
this  means  his  general  mental  capacity  will  be  gauged,  and  the 
examiner  will  be  able  to  form  an  opinion  as  to  whether  he  has 
sufficient  wit  to  take  care  of  himself.  If,  in  spite  of  his  mental 
dullness,  he  seems  intelligent  enough  to  follow  an  occupation,  and 
to  look  after  his  interests  with  ordinary  prudence,  then  he  is  not 
defective.  The  subject  of  moral  defect  will  be  considered  in  a 
separate  chapter. 

Children  of  Delayed  Mental  Development. — We  now  come  to  a 
group  of  children  of  a  totally  different  kind,  the  Retardation^  of 
mental  _d£-velopment- -being  only  temporary.  This  condition, 
unlike  the  preceding,  is  much  commoner  in  our  large  towns  than 
in  the  country,  and  it  often  simulates  real  amentia  so  closely 
that  for  a  time  a  diagnosis  may  be  impossible. 

It  has  already  been  stated  that  certain  factors  of  the  environ- 
ment may  possibly,  but  very  occasionally,  produce  mental 
defect.  More  commonly,  however,  the  insufficient  and  improper 
feeding,  the  absence  of  fresh  air  or  warmth,  and  the  general  neg- 
lect which  unfortunately  attaches  to  the  early  life  of  many  of  the 
children  in  our  densely  populated  industrial  centres,  produce  a 
retardation  of  mental  growth  which  is  not  permanent,  and  is  not 
therefore  amentia.  In  real  amentia  there  is  either  an  actual  and 
permanent  arrest  or^arTincapacity  for  perfect  development,  owing 
to  a  blight  of  the  seed.  In  these  cases  it  is  the  soil  which  is 
unsatisfactory,  and  the  condition  may  not  inaptly  be  compared 
to  the  late  opening  of  the  flower-buds  in  consequence  of  chill 
winds  and  absent  sun.  It  is  what  may  be  described  as  a  late 
Spring,  and  the  characteristic  of  these  cases  is  that  under  mo.e 
congenial  surroundings  the  brain  rapidly  recovers,  and  the  child 
soon  regains  the  normal  standard.  It  may  be  several  years  before 
this  change  takes  place,  and  it  often  does  so  with  surprising 
suddenness  ;  so  that  the  child  who  has  hitherto  been  dull,  vacant, 


144  Mental  Deficiency 

and  apparently  suffering  from  undoubted  mental  deficiency, 
astonishes  everybody  by  suddenly  waking  up. 

I  have  already  referred  to  these  cases,  and  have  shown  that 
they  form  a  variable,  but  often  considerable,  proportion  of  the 
pupils  of  "  special  "  schools.  There  is,  of  course,  no  objection 
to  their  admission  to  these  schools — in  fact,  the  individual  atten- 
*tion  and  special  training  thereby  afforded  are  the  very  best  things 
for  them.  It  is,  however,  extremely  desirable  that  the  condition 
should  not  be  confounded  with  real  defect,  as  this  leads  to 
entirely  fallacious  ideas  as  to  the  prevalence,  causation,  and 
curability  of  amentia.  It  must  be  admitted  that  the  diagnosis 
is  often  extremely  difficult,  and  may  be  impossible  until  the 
touchstone — special  training — has  been  applied.  I  think,  how- 
ever, that  if  the  examination  reveals  an  entire  absence  of  morbid 
inheritance,  if  there  are  no  stigmata  of  degeneracy  nor  signs  of 
uTegular  nerve  action,  and  if  the  state  of  nutrition  is  poor  and  the 
environment  is  known  to  be  bad,  that  then  there  are  grounds  for 
suspecting  that  the  case  is  one,  not  of  arrested,  but  of  retarded, 
development,  and  the  diagnosis  must  be  provisional  accordingly. 

Dullness  due  to  Disease. — Children  suffering  from  defects  of 
vision,  hearing,  speech,  or  from  serious  constitutional  disease, 
often  appear  to  be  dull  and  stupid,  and  might  possibly  be  thought 
to  be  mentally  defective.  I  do  not  think  that  the  physician 
would  be  very  likely  to  fall  into  this  error,  but  it  is  necessary 
to  bear  the  fact  in  mind,  as  such  a  mistake  is  often  made  by 
school-teachers.  I  have  had  boys  and  girls  produced  as  cases 
of  serious  defect  who  merely  wanted  the  attention  of  the  oculist 
or  nose  and  throat  specialist,  and  I  have  examined  a  child 
returned  as  defective  who  was  mentally  sound,  but  suffering  from 
severe  pulmonary  tuberculosis.  Ordinary  care  should  suffice  to 
prevent  these  mistakes,  although  the  presence  of  illness  or  disease 
does  not,  of  course,  negative  mental  defect. 

Another  condition,  more  often  seen  in  the  consulting-room 
than  the  school,  which  may  give  rise  to  a  suspicion  of  amentia 
is^^tiiat  of  nervous  exhaustion.     The  child  is  dull,  listless,  and 


inattentive.  He  cannot  be  gSt  to  answer  questions,  and  if  given 
a  simple  sum  he  does  it  wrong.  His  co-ordination  is  imperfect, 
his  memory  is  faulty,  there  is  often  tremor,  his  head  may  be  small 
and  asymmetrical,  and  his  lower  eyelids  are  baggy  and  relaxed. 


Feeble-Mindedness  in   Children 


The  history  will  generally  show  that  the  mental  hebetude  i 
recent  origin,  and  that  previously  the  child  has  been  of  ordin 
sometimes  unusual  brightness  ;  but  as  against  this  the  inqi 
may  elicit  a  neuropathic  family  history.     The  condition  hei 
probably  one  of  neurasthenia  in  a  child  with  but  a  small  reserv    of 
nerve  force.     It  is  often  accompanied  by  severe  headache,  ai 
usually  the  result  of  overpressure.     These  children  form  the  v:    > 
from  which  a  considerable  proportion  of  the  insane  population  is 
drawn,  and  although  most  cases  recover  under  suitable  treatment, 
the  dullness  of  mind  occasionally  persists  until  the  child  becomes 
a  complete  mental  wreck.     In  older  children  this  state  may  owe 
its  origin  to  masturbation. 

Epilepsy. — It   is   necessary  to   remember  that,  although  the 
mentally  defective  child  may  be  subject  to  fits,  epilepsy  m.ay 
give  rise  to  a  transitory  mental  dullness  which  is  not_amenu-i?. 
In  most  of  these  cases  there  \^all  be  a  history  of  fits,  but  they  u 
be  nocturnal  only,  and  unknown  to  the  parents.     The  phys; 
"will  then  have  to  be  guided  by  the  loss  of  memory  an«.l  altema  ^ 
brightness  and  stupidity,  which  have  little  in  common  with 
fixed  mental  state  of  the  real  defective.     In  many  of  these  cases, 
however,  amentia,  and  subsequent  dementia,  may  be  induced 

Insanity  might  possibly  be  confused  with  mental  defect, 
the  relative  rarity  of  this  condition,  and  the  usually  evident  i;.:. 
that  the  child  is  suffering  from  a  disorder,  and  not  an  arrest  of 
mm37ought  to  prevent  such  a  mistake. 

Imbecility. — Having  ascertained  that  the  mental  condition 
the  child  under  examination  is  not  due  to  disease  or  ill  -beaj '    ,   • 
is  not  merely  dullness  and  backwgrdness,  but  is  really  or 
deficiency,  the  physician  who  is  examining  for  the  purpose 
certification  to  a  special  school  will  be  required  to  exclude  im- 
becility.    In  pronounced  cases  of  this  latter  there  will  be  no 
difficulty,  but  in  the  milder  degrees  a  differential  diagnosis  will 
be  far  from  easy.     The  following  points  may  be  found  of  assist- 
ance : 

As  a  rule,  the  mentally  defective  school  child  knc  .s  the  na:u- 
of  common  objects,  and  can  give  some  account  of  th'ir  use,  wliil^t 
the  imbecile  of  corresponding  age  is  generally  la     ing  in  thi- 
knowledge,    ^^either  child  may  know  his  letters,  bui  the  mental  > 
defective  will  usually  recognize  and  name  various  articles  sho\ 

10 


146  Mental  Deficiency 

to  him  in  pictures.  Speech  is  often  a  valuable  indication,  although 
it  is  to  be  remembered  that  many  merely  feeble-minded  children 
speak  exceedingly  badly.  It  is  rather  the  matter  than  the 
manner  of  speech  which  must  be  attended  to,  as  showing  the 
degree  of  general  intelligence.  Some  imbeciles  will  repeat  ques- 
tions ;  others  obviously  fail  to  understand  what  is  said  to  them  ; 
others  ramble  on  in  an  utterly  nonsensical  manner,  and  are  quite 
incapable  of  carrying  on  the  simplest  conversation.  The  inability 
to  execute  some  simple  command  or  the  manner  of  doing  so  often 
affords  most  useful  information.  Above  all,  however,  the  im- 
becile is  markedly  deficient  in  common  sense.  He  can  rarely  be 
depended  upon  to  perform  any  simple  errand  or  task  unless 
watched  the  whole  time,  and  he  often  will  sit  outside  in  the  rain 
and  get  wet  through  without  making  the  slightest  effort  to 
shelter. 

If  there  should  be  any  doubt  in  the  examiner's  mind,  then  I 
think  it  is  kinder  to  give  the  child  the  benefit  of  it.  It  may  seem 
a  small  matter,  but  it  is  to  be  remembered  that  for  children  of 
the  working  classes,  who  cannot  afford  to  pay  considerable  fees, 
the  only  alternative  to  the  special  school  is  often  the  workhouse 
or  county  asylum.  Excellent  special  idiot  asylums  exist,  it  is 
true,  but  in  the  absence  of  means  admission  into  these  is  often  a 
tedious  process.  I  should  certainly  hesitate  to  commit  a  possibly 
improvable  case  to  an  institution  which  does  not  profess  to  have 
training  facilities,  until  he  had  been  tried,  and  found  wanting,  in 
a  special  school. 


CHAPTER  IX 

FEEBLE-MINDEDNESS  IN  ADULTS 

Definition. — ^The  term  feeble-minded  person  is  applied  to  an 
individual  suffering  from  the  mildest  degree  of  amentia,  who  is 
over  the  age  of  sixteen  years,  those  under  this  age  being  known 
as  "  mentally  defective  children." 

The  feeble-minded  person  is  defined  as  "  one  who  is  capable  of 
earning  a  living  under  favourable  circumstances,  but  is  incapable, 
from  mental  defect  existing  from  birth  or  from  ah  early  age,  {a)  of 
competing  on  equal  terms  with  his  normal  fellows,  or  (&)  of  manag- 
ing himself  and  his  affairs  with  ordinary  prudence.'' 

Number. — ^The  inquiries  of  the  Royal  Commission  show  that 
about  40  per  cent,  of  all  aments  in  this  country  are  feeble-minded 
persons,  and  I  calculate  that  in  England  and  Wales  on  January  i, 
1906,  their  approximate  total  was  54,114.  This  number  is  rather 
less  than  half  the  total  insane  on  the  same  date,  and  corresponds 
to  I  -57  feeble-minded  persons  in  every  1,000  population.  But  the 
incidence  is  not  uniform  throughout  the  country ;  it  varies 
directly  with  the  prevalence  of  mental  abnormality  in  general 
(which  is  subject  to  a  very  considerable  range  of  variation)  ;  it 
also  differs  according  to  the  environment.  The  prevalence  in 
the  respective  areas  investigated  has  been  shown  in  Tables  I.  and 
IV.,  pp.  6  and  10,  from  which  it  is  seen  that  the  feeble-minded 
adult,  both  absolutely  and  relatively,  tends  to  be  commoner  in 
agricultural  than  in  urban  districts. 

The  cause  of  this  is  not  at  first  sight  clear,  for  these  persons  are 
but  grown-up  defective  children,  and  this  latter  class  is  apparently 
much  more  numerous  in  the  towns  than  in  the  country.  As  I 
have  shown,  however,  there  is  good  reason  for  thinking  that  a 
large  proportion  of  the  so-called  mentally  defective  children  of 

147  10—2 


Feeble- Mindedness  in  Adults  149 

which  they  are  familiar,  and  they  cannot  rise  to  any  work  or 
circumstances  outside  their  daily  routine.  They  still  show  the 
^ame  larT^  of  nhsprvation  and  reasoning  power,  they  have  little 
vvy  ability  to  generalize  or  to  apply  their  limited  knowledge  to  new 
conditions,  and  their  ideas  still  retain  much  of  the  crudity  of 
childhood.  It  results  from  this  that,  although  the  feeble-minded 
adult  may  be,  and  often  is,  capable  of  useful  employment  of  a 
routine  nature  under  supervision,  he  is  as  a  rule  incapable  of 
steeringhis  own  course,  or  even  of  providing  lor  nimsell  mthouf^^ 
some  assistance.  And  when  contrasted  with  a  normal  indi- 
vidual of  similar  age,  his  lack  of  mental  capacity  is  even  more 
prominent  than  in  the  case  of  the  defective  child. 

On  the  whole,  I  think  that  the  foregoing  description  is  applic- 
able to  the  bulk  of  the  feeble-minded  ;  but  it  must  be  remem- 
bered that  there  are  many  degrees,  and  that  no  account  can  be 
given  which  would  fit  every  member  of  the  class.  This  descrip- 
tion is  probably  too  flattering  to  some  of  the  more  pronounced 
defectives  ;  on  the  other  hand,  to  the  highest  types  of  all  such 
an  account  may  be  somewhat  unfair,  for  many  of  these  are 
tolerably  well  grown  and  developed,  and  show  little  indication 
of  their  weakness  if  they  are  not  scrutinized  too  carefully. 
Those  of  this  mild  grade  belonging  to  the  upper  and  wealthier 
classes — for  poverty  has  no  monopoly  of  feeble-mindedness — 
do  not  usually  find  the  daily  round  of  society  beyond  their 
capacity  ;  they  even  marry  or  are  given  in  marriage,  and  it  is 
only  when  a  situation  arises  which  calls  for  management  and 
judgment  that  their  defect  becomes  patent.  So  long  as  they 
are  under  supervision  they  pass  muster,  but  once  let  them  take 
the  reins  and  chaotic  disaster  speedily  results. 

"It  is,  however,  rather  in  the^  matter _of  character  that  the 
greatest  difference  exists  between  the  grown-up  and  juvenile 
feeble-minded.  Ordinary  persons  approximate  to  one  common 
type  much  more  in  childhood  than  in  adult,  life,  and  although 
individual  differences  are  observable  from  the  first  few  weeks 
of  life,  they  become  much  more  pronounced  about  the  age 
of  puberty.  So  it  is  with  the  feeble-minded.  The  advent  of 
puberty  often  sees  ihe  evolution  ol  nabits  ana  propensities  which 
have  the  greatest  effect  upon  the  future  life,  and  which  have 
hitherto  been  latent.     Possibly  to  a  considerable  extent  these 


150  Mental  Deficiency 

may  be  dependent  upon  the  early  environment  and  training,  or 
absence  of  training  ;  but  heredity  often  plays  an  important  part, 
as  in  the  ordinary  child.  Whatever  their  origin,  the  mental 
defect  and  lessened  power  of  control  of  these  persons  tend  to 
bring  these  habits  and  propensities  into  extreme  prominence. 

These  propensities  are  many  and  varied,  and  from  the  point  of 
view  of  administration  they  demand  the  closest  attention. 
Indeed,  I  would  go  so  far  as  to  say  that,  in  dealing  with  the  feeble- 
minded, there  could  be  no  greater  administrative  blunder  than 
/to  tr^at  mental  defect  m  the  abstract  and  pay  no  regard  to  these 
peculiarities  of  the  individual.  Some  feeble-minded  persons  are 
placid,  well-behaved,  and  industrious  ;  others  are  perfectly  harm- 
less, but  possess  pronounced  wandering  proclivities  ;  others  are 
exceedingly  facile  ;  whilst  yet  others  have  a  strong  predisposition 
to  insanity  or  crime.  On  the  whole,  I  think  that  all  of  them  may 
be  divided  into  two  main  clashes,  according  as  their  mental  equi- 
librium tencis  to  be  stable  or  uiistable,  and  these  we  may  briefly 
describe. 

Feeble-minded  of  Stable  Mental  Equilibrium. — Many  feeble- 
minded persons  are  quiet,  placid,  inoffensive,  and  good-natured 
individuals  who  go  on  their  way  comparatively  unmoved  by  the 
happenings  of  life.  They  are  not  insensible  to  pleasure,  and 
they  evince  a  certain  amount  of  delight,  just  as  would  a  child,  at 
a  theatre,  a  circus,  the  sight  of  a  company  of  soldiers,  or  the  like. 
They  are  also  conscious  of,  and  affected  by,  praise,  rebuke,  or  ill- 
treatment  ;   but  their  jr>y  frr^nrrnyr  ig  r|pitVipr  ovreggivt^  nor  of 

long  duration,  and  their  general  demeanour  is  4hat  of  happy 
placidity.  The  mental  constitution  of  such  persons  is  in  striking 
contrast  to  that  of  the  class  we  shall  next  consider,  and  they  may 
be  appropriately  designated  as  of  stable  equilibrium.  I  can  give 
no  precise  figures,  but  my  impression  is  that  this  type  comprises 
about  30  to  40  per  cent,  of  all  the  feeble-minded.  Owing  to  the 
present  laclcof  organization  for  providing  these  persons  with 
suitable  employment,  a  considerable  number  of  them  are  idle, 
and  spend  their  time  roaming  the  villages  and  country  lanes  ; 
but  most  of  these  will  cheerfully  carry  a  parcel  or  do  any  odd 
jobs  they  may  be  asked  to  do,  and  those  for  whom  continuous 
employment  is  found  prove  themselves  to  be  steady,  industrious 
workers.     Illustrations  of  this  type  are  shown  in  Plate  IV. 


Plate  IV. 


To  face  page  1 50.  ] 


Feeble-Mindedness  in  Adults  151 

In  the  country  a  certain  number  of  them  are  employed  upon 
the  land  in  some  simple  capacity,  such  as  helping  with  the 
hay  or  corn,  the  plough  or  roots,  scaring  the  birds,  or  bringing 
up  the  cows  ;  and  although  they  cannot  be  trusted  to  do  the  full 
work  of  an  agricultural  labourer,  they  often  take  the  place  of  a 
boy  to  the  satisfaction  of  their  employer,  and  they  are  quite 
worth  their  keep  and  the  shilling  or  two  a  week  they  receive. 
It  is  probable  that  most  moderate-sized  villages  possess  at  least 
one  of  these  "  softies,"  "  naturals,"  "  dafties,"or  ''  not  exactlies," 
as  they  are  called  ;  and  although  they  are  at  times  made  fun  of  by 
the  urchins  of  the  place,  they  are  not,  as  a  rule,  unkindly  treated. 
In  the  towns,  on  the  other  hand,  this  type  is  not  nearly  so  common. 
Such  persons  may  occasionally  be  seen  selling  newspapers,  dis- 
tributing bills,  hawking  firewood,  or  doing  odd  jobs  for  some 
charitably  disposed  person  ;  but  the  increased  competition  of 
town  life  is  decidedly  against  them,  and  they  rapidly  tend  to  be 
squeezed  further  afield  or  to  gravitate  into  the  workhouse  or 
some  charitable  institution. 

The  life  of  these  persons  is  one  of  rnnformity  tp  h^bitj  and  not 
to  ideals.  They  rf^reljMjrjrik  of,  much  ^^^^  rn^kp  pl_ans  for,  the 
future  ;  and  the  few  who  have  vain  imaginations  as  to  what  they 
would  like  to  do  or  become  are  lacking  in  tjie^  necessary  intelli- 
gence  or  will  to  direct  their  actions  accordingly.  Indeed,  one  of 
the  most  pronounced  features  of  the  feeble-minded  person  is  his 
utter  lackj:ii4im:£ose.  If  given  work  and  told  exactly  what  to 
do,  he  may  often  be  trusted  to  do  it  ;  he  may  even  acquire  the 
habit  of  performing  the  same  task  day  after  day,  year  in  and 
year  out,  without  supervision.  But  the  work  must  be  strictly 
of  a  routine  nature,  for  he  would  be  quite  unable  to  cope  with 
any  unforeseen  occurrence.  And  should  he  lose  his  employment, 
he  is  incapable  of  any  strenuous  attempt  to  seek  more.  To  use 
a  homely  phrase,  we  may  say  that  the  bread  of  these  persons 
must  be  put  into  their  mouths. 

The  following  is  a  fairly  typical  illustration  of  this  stable  type 
of  high-grade  feeble-mindedness  : 

^.  C.  is  a  man  of  twenty-two  years,  although  he  looks  only 
about  seventeen.  He  went  to  an  ordinary  elementary  school, 
and  was  in  the  sixth  standard  when  he  left  ;  but  his  school- 
master tells  me  that  he  was  only  moved  up  each  year  on  account 


152  Mental  Deficiency 

of  his  size  and  age,  and  that  his  scholastic  attainments  were  really 
only  equal  to  Standard  III.  During  the  two  years  following 
school  he  had  several  situations,  mostly  as  errand-boy,  but  he 
was  discharged  from  each  place  in  turn  on  account  of  general 
incompetency.  Then  he  was  taken,  largely  from  philanthropic 
motives,  into  a  printing-office,  and  there  he  has  remained  until 
the  present  time.  His  work  is  purely  mechanical,  and  consists 
in  helping  a  man  with  the  machine,  carrying  bales  of  paper,  and 
so  on.  He  began  with  a  wage  of  nine  shillings  weekly  ;  this 
has  been  increased,  and  he  now  has  a  standing  wage  of  eleven 
shillings,  but  he  often  puts  in  overtime,  and  he  usually  earns 
about  thirteen  shillings.  He  lives  at  home  with  his  parents,  and 
he  gives  his  money  to  his  mother,  who  allows  him  a  shilling 
weekly  as  pocket-money.  When  clothing  or  boots  are  required, 
his  mother  buys  them,  and,  in  fact,  he  is  treated  exactly  as  a 
child.  He  is  perfectly  happy  and  contented  with  his  lot,  and 
has  no  ambition  to  be  other  than  what  he  is  ;  but  it  is  difficult 
to  say  what  is  going  to  happen  when  he  has  no  home  to  go  to 
and  no  parents  to  look  after  him.  I  asked  him  if  he  had  ever 
thought  of  getting  married.  He  said  :  ''  No."  I  asked  him  if  he 
ever  kept  company  with  anyone.  He  said  he  did  for  a  time, 
and  used  to  "  walk  out  "  with  a  girl  every  night.  To  my  ques- 
tions as  to  what  he  used  to  say  to  her,  he'  said  :  "  She  used  to  ask 
me  how  I  was  getting  on  at  my  work.  I  said  :  '  Pretty  fair.'  I 
used  to  ask  her  how  she  was  getting  on  at  her  work.  She  said  : 
*  All  right.'  "  There  do  not  appear  to  have  been  many  love- 
passages,  for  he  admits  that  he  never  kissed  her.  After  six 
months  the  maiden  tired,  and  she  now  walks  out  with  one  of  his 
more  enterprising  mates.  This  youth  once  conceived  the  desire 
to  join  the  Volunteers,  and  applied  to  the  local  non-commis- 
sioned officer.  The  Sergeant-Major,  a  shrewd  man  and  a  good 
judge  of  men,  rejected  him,  and,  when  I  asked  if  he  didn't  come 
up  to  the  physical  standard,  said  :  "  His  body  was  all  right,  sir  ; 
but  he  had  too  Httle  brain-pan."  He  has  a  few  stigmata,  can 
read  and  write  tolerably  well,  and  can  do  simple  sums  ;  he  can 
also  copy  drawing  very  creditably,  but  he  has  little  other  know- 
ledge. After  a  good  deal  of  consideration,  he  told  me  that  history 
was  "  what  happened  before,"  and  that  geography  was  "  about 
towns  and  rivers,"  but  he  has  no  historical  or  geographical 


Feeble- Mindedness  in  Adults  153 

knowledge.  I  asked  him  which  was  the  first  war  that  he  learned 
about.  After  much  cogitation  he  said  :  "  It  was  near  Trafalgar 
Day.  It  was  when  Nelson  fought.  He  defeated  the  Spaniards." 
On  being  asked  how  long  ago  that  happened,  after  a  very  long 
pause  he  said  :  ''  From  then  to  now,  do  you  mean  ?"  and,  on  my 
replying  in  the  affirmative,  said  :  "  About  seven  hundred."  His 
knowledge  of  geography  was  of  the  same  order,  and  although 
he  told  me  he  had  got  a  Sunday-school  prize,  to  my  query  as  to 
who  God  was  he  replied,  after  much  thought  :  "  The  Son  of 
man." 

I  am  acquainted  with  a  feeble-minded  man,  John  C ,  who 

has  steadily  and  industriously  cracked  stones  by  the  roadside  for 
the  past  forty  years.  He  lodges  in  the  village  with  a  labourer 
and  his  wife,  and  the  latter  wakes  him  in  the  morning,  gives  him 
his  breakfast,  makes  his  dinner  into  a  parcel,  and  sends  him  off 
to  work.  When  dinner-time  comes,  which  he  knows  by  seeing 
the  labourers  in  the  field  leave  of£  work,  he  eats  the  contents  of 
his  parcel.  Sometimes  John  feels  hungry,  and  eats  it  before. 
About  five  o'clock,  w^hich  he  also  knows  by  the  passing  of  the 
postman,  he  leaves  off  work  and  returns  to  his  lodging.  He  has 
his  tea,  sits  by  the  fireside  until  about  eight,  and  then  goes  to 
bed.  Occasionally  John  has  been  known  to  get  tired  of  work 
and  come  home  in  the  middle  of  the  afternoon  ;  but  such  lapses 
are  very  rare,  and  on  the  whole  he  is  exceedingly  methodical 
and  industrious.  He  knows  that  Sunday  is  a  day  of  rest,  but 
he  must  be  told  that  it  is  Sunday,  or  he  would  go  to  work  as 
usual.  John's  landlord  once  played  him  the  prank  of  not  telling 
him  it  was  the  Sabbath,  and  he  went  off  as  usual  without  any 
suspicion.  But  he  had  intelligence  enough  to  notice  the  trick 
on  passing  through  the  village,  by  seeing  that  the  shop  was 
closed,  and  he  came  back  vastly  amused  at  what  he  thought 
was  a  fine  mistake.  He  receives  a  few  shillings  each  week  from 
the  Rural  District  Council,  and  this  he  faithfully  carries  to  his 
landlady,  who  allows  him  a  penny  now  and  then  when  he  asks 
for  it.  This,  however,  appeared  to  be  seldom,  for  John  seems 
to  be  in  the  happy  condition  of  having  all  his  wants  supplied. 

One  might  describe  many  cases  similar  to  these,  both  in  town 
and  country  ;  but  it  is  unnecessary.  They  illustrate  very  well 
the  stable  type  of  feeble  mind,  and  the  manner  in  which  routine 


154  Mental  Deficiency 

work  may  be  performed  by  this  class  with  comparatively  little 
supervision.  I  have  even  known  several  who  have  served  their 
time  in  the  army.  It  is  necessary,  however,  to  remember  that 
their  intelli£;ence  is  limited,  and  that  these  persons  must  not  be 
><^^-^  entrusted  with  work  beyond  theinxapacity.  or  the  result  may  be 
disastrous.  I  may  mention  a  striking  example  of  this  which 
occurred  in  the  case  of  a  feeble-minded  woman  resident  in  a  work- 
house. Her  daily  occupation  was  washing  in  the  laundry,  which 
she  did  very  well.  But  one  day  the  charge-nurse  of  the  maternity 
ward  most  unfortunately  gave  her  a  baby  to  wash.  She  did  so 
in  boiling  water,  with,  it  need  hardly  be  said,  a  fatal  result. 

But  although  these  persons  are  capable  of  useful  employment, 
they  have  no  capacity  to  lay  out  the^moneyL±hey-«arn  or  to 
manage  their  affairs.  Food,  clothing,  and  shelter  must  be  pro- 
vided for  them,  just  as  with  children,  and  in  the  absence  of  some 
one  to  look  after  them  they  soon  get  into  a  most  woeful  plight. 

As  an  instance  of  their  general  "  incapacity  to  manage  their 
affairs  with  ordinary  prudence,"  I  may  mention  the  case  of  a 
woman  I  met  in  a  small  village  in  Somerset.  She  was  the 
daughter  of  the  village  shopkeeper,  and  upon  her  parents'  death 
had  inherited  sufficient  cottage  property  to  keep  her  in  comfort 
for  the  rest  of  her  life.  Unfortunately,  however,  no  one  was 
appointed  to  look  after  her,  and  so  it  came  about  that  little  by 
little  she  was  diddled,  by  relatives  and  acquaintances,  out  of 
every  penny  she  possessed,  and  when  I  saw  her  she  had  been 
taken  in  out  of  pity  by  the  wife  of  a  labouring  man,  who  received 
a  few  shillings  weekly  from  the  parish  to  look  after  her. 

Throughout  the  country  there  are  hundreds  of  feeble-minded 
persons,  many  of  them  gentlefolk  by  birth,  in  like  case.  As  long 
as  they  are  provided  with  a  home,  and  have  parents  or  relations 
to  generally  supervise  them,  things  go  well.  They  perform  little 
household  and  outdoor  duties,  take  up  simple  hobbies  like  poker- 
work,  stamp-collecting,  and  amateur  cabinet-making,  and  enter 
into  the  ordinary  social  amusements  of  the  class  to  which  they 
belong.  Most  of  their  friends  recognize  that  they  are  not  quite 
"  all  there,"  but  they  often  pass  muster  with  casual  acquaint- 
ances. But  once  let  them  get  away  from  the  parental  apron- 
strings,  and  assume  the  responsibilities  of  an  independent 
existence,  and  their  want  of  mental  capacity  is  fully  revealed, 


Plate  V. 


3  a, 
o  ■*-■ 


c  o; 

3-C 


II 


To  /ace  page  154.] 


Feeble-Mindedness  in  Adults  155 

and  results  in  their  complete  undoing.  In  the  case  of  feeble- 
minded girls  this  general  inability  to  take  care  of  themselves 
is  particularly  evident,  and  demonstrates  in  the  most  forcible 
manner  the  urgency  of  the  need  for  their  protection. 

Lastly,  it  may  be  said  that,  although  the  religious  and  moral 
sense  of  these  persons  ^rarely^of_aJiigh  order,  most  of  them  are 
conscious  of  the  difference  between  right  and  wrong,  and  of  the 
fact  that  they  have  certain  obhgations  towards  their  neighbours. 
A  goodly  number,  indeed,  are  quite  capable  of  understanding 
simpk-theological  doctrine. 

Feeble-minded  of  Unstable  Mental  Equilibrium. — It  is  not,  per- 
haps, surprising  that  the  mind  which  is  defective  should  also  lack 
balance,  and  in  a  very  considerable  number  of  feeble-minded 
persons — inde£d».I^ink  in  the  ma.]ority^^^^e_T£i^ii^ial-d£iect  is 
accompanied  by  more  or  less  mental  instability...  This  may  not 
become  evident  until  the  physiological  epochs  _Ql_imbertv  or 
^  adolescence  have—been  reached^-andnone  meets  many  cases  in 
"which  the  whole  disposition  of  the  individual  seems  to  undergo 
an  alteration  at  these  times  ;  but  often  the  condition  can  be 
detected  in  childhood,  and  is  shown  by  the  fits  of  irritability, 
excitement,  moroseness,  suJkiness,  or  so-called  ''  bad  temper," 
which  are  present  in  a  considerable  number  of  defective 
children. 

The  degrgg_o^f  instability  varies  much  in  different  individuals, 
and  ardi^reht  timesTn  the  s"Sie7ndivMnal.  Sonie  are  simply 
gigglin^^  emotional,  and  irnpulsive,  liable  to  sudden  fits  of  way- 
wardness, but  readily  controllable,  and  on  the  whole  capable  of 
doing  useful  work.  In  these  the  attack  has  much  of  the  character 
of  an  epileptic  seizure.  I  have  known  one  of  this  type,  a  silly, 
giggling,  weak-minded  girl,  to  plunge  her  head  into  a  pail  of 
water  without  the  slightest  hesitation  when  the  suggestion  was 
made  to  her.  I  have  known  another  to  set  fire  to  a  hay-rick, 
and  another  to  dash  her  hand  violently  through  a  window-pane 
in  a  sudden  access  of  temper.  And  yet  all  of  them,  -on  the 
whole,  were    good,   willing    workers    and    in    fairly  .constant 

employment  (see  Plate  V.).  "~~ ^ 

In  others,  however,  the  instability  is  more  persistent,  and  the 
person  is  so  changeable  and  undependable  that  continuous  em- 
plo5mient  is  out  of  the  question  unless  the  closest  supervision  can 


156  Mental  Deficiency- 

be  maintained.  Many  of  these  are  girls,  and  the  following  case 
is  a  very  good  example  of  the  type  : 

Alice  S is  a  feeble-minded  girl  of  nineteen  years.     She  is 

the  daughter  of  working  people,  and  went  to  the  Board-school 
until  she  was  fourteen  years  of  age  ;  but  her  schoolmistress  says 
she  could  make  nothing  out  of  her,  that  when  she  left  she  could 
only  just  read  and  write,  and  that  she  was  "  always  spiteful, 
untrustworthy,  and  a  regular  nuisance."  Upon  leaving  school 
a  situation  as  day-girl  was  found  for  her.  She  ran  away  on  the 
third  day,  and  refused  to  go  back.  Then  she  got  another  place, 
but  only  stayed  a  week,  as  her  mistress  "  could  not  put  up  with 
her  ways."  This  went  on  for  over  two  years,  during  which  time 
she  had  no  fewer  than  twenty- two  situations.  She  was  then 
sent  to  a  laundry  training  home,  and  here  for  the  first  few  weeks 
she  was  much  quieter,  and  it  was  hoped  that  she  would  settle 
down  into  good  habits.  But  the  hope  was  futile.  The  matron 
found  that  not  the  slightest  dependence  ■  could  be  placed  upon 
her  word,  that  she  was  dirty  in  her  person,  lazy,  an  incurable 
pilferer,  and  up  to  the  most  cunning  tricks  to  annoy  and  irritate 
her  companions.  She  was  therefore  sent  home  again.  Here 
she  remained  for  some  months,  doing  no  work,  and  causing  her 
relations  endless  trouble  and  worry.  On  several  occasions  she 
was  brought  home  by  the  police,  and  finally,  within  a  year  of  her 
return  from  the  training  home,  she  was  admitted  into  the 
maternity  ward  of  the  workhouse.  It  was  there  that  I  first  saw 
her,  and  although  she  was  a  strong,  active  girl,  and  quite  capable 
of  doing  domestic  work,  she  was  nevertheless  so  erratic,  impulsive, 
and  generally  irresponsible,  that  nothing  could  be  made  of  her. 

The  following  is  a  somewhat  similar  case  : 

F.  H.,  a.  feeble-minded  man  twenty-three  years  of  age,  having 
the  appearance  of  a  youth  of  seventeen  or  eighteen.  He  is  5  feet 
in  height,  and  weighs  7J  stones,  is  thin  and  ill-nourished,  and 
has  numerous  stigmata.  He  is  extremely  unstable,  at  times 
being  quiet  and  well-behaved,  at  others  noisy,  restless,  talking  and 
laughing  to  himself,  and  interfering  with  those  around  him.  In 
one  of  these  fits  he  attacked  his  brother  with  a  hammer.  He  has 
had  several  situations,  but  has  been  unable  to  keep  any  of  them. 
He  can  read,  write,  and  do  simple  sums,  and  although,  when 
questioned,  he  seems  to  have  a  fair  knowledge  of  many  common 
things,  he  is  too  defective  and  unstable  to  turn  his  knowledge  to 


Feeble-Mindedness  in  Adults  157 

any  account.  He  is  a  ready  talker  when  in  the  mood,  and  gives 
a  very  plausible  account  of  himself.  He  says  he  is  "  what  you 
call  an  orphan,  and  only  has  his  brothers  to  be  acquainted  with 
now.  Was  in  the  sixth  standard  when  he  left  school,  and  used 
to  do  reading,  writing,  arithmetic,  composition,  and  geometry ; 
was  never  at  the  top  of  the  class — master  used  to  think  him  a 
backward  boy.  It  was  writing  from  memory  that  was  his  worst 
subject  ;  memory  was  always  bad.  Once  got  a  prize  for  religious 
catechism.  Was  in  the  bo};^'  home  learning  printing  for  nine 
months,  but  they  gave  him  the  sack  because  he  accidentally 
spoilt  a  special  job.  Has  had  other  chances,  but  never  seemed 
to  get  on  very  well.  If  they  would  only  give  him  another  chance 
he  would  do  his  very  best.  Several  of  the  other  people  have 
interfered  with  him,  and  then,  of  course,  he  has  to  take  care  of 
himself.  One  of  his  masters  told  him  he  would  get  on  better  if 
he  didn't  allow  himself  to  be  put  on,  and  looked  after  himself 
more." 

Lastly,  in  another  group  of  these  unstable  feeble-minded  a 
condition  of  actual  insanity  is  present  ;  but  as  this  is  a  com- 
plication of  some  importance,  I  shall  deal  with  it  in  a  subse- 
quent chapter. 

As  already  remarked,  it  is  likely  that  a  good  deal  of  the  mental 
instability  of  these  persons  is  the  result  of  an^unsuitable  enyiron- 
menljii  early  lite,  andTt  is  probable  that  careful  and  firm  training 
during  childhood  might  do  much  to  prevent  it.  I  am  certain, 
however,  that  it  is  often  inborn,  just  as  is  that  instability  of 
mental  constitution  in  the  ' '  normally  "  developed"  which" is^  so 
often  the  precursor  of  insanity  ;  indeed,  I  am  inclined  to  look 
upon  aTTfeeble-rninded  persons  of  this  type  as  potentialhmatics. 

It  is  easy  to  understand  that  criminal  actions  may  be  committed 
by  such  persons,  and  there  is  no  doubt  that  they  constitute  the 
£^reRjjiiRJniniyjif^^  criminals.     Also,  although  prob- 

ably not  so  often  the  case  to-day,  there  is  little  doubt  that  in 
years  gone  by  those  of  the  facile  type  were  frequently  made  use 
of  to  further  the  schemes  of  the  professional  law-breaker.  It  is 
not  merely  that  these  persons  are  incapable  of  appreciating  the 
consequences  of  their  actions — for  that  might  be  said  of  most 
of  the  feeble-minded — it  is  rather  that  their  defect  is  accom- 
panied by  such  a  general  instability  of_jaiii;d  that  they  are 
either  pernh'^jjj^  <;ngrppf j|^1p  f^  ^riy  sugg^^gfi^n^  or  are  liable  to 


158  Mental  Deficiency- 

flare  up  for  the  most  trivial  cause.  The  train  is  already  laid  ; 
it  is  only  the  spark  that  is  needed.  It  is  obvious  that  feeble- 
minded persons  of  this  type  are  much  more  likely  to  come  into 
contact  with  the  authorities  than  are  the  harmless,  placid  indi- 
viduals previously  described  ;  and,  as  a  matter  of  fact,  a  very  large 
number  of  them  are  inmates  of  our  workhouses,  prisons,  asylums, 
or  charitable  homes.  Still,  the  number  at  large  throughout  the 
country  is  not  inconsiderable,  as  is  shown  by  the  investigations 
of  the  Royal  Commission. 

To  this  account  of  the  chief  characteristics  of  high-grade  amentia 
we  may  add  that,  although  defect  may  be  especially  pronounced 
in  some  one  particular  faculty,  there  is  no  one  single  defect  which 
is  typical  of  the  feeble-minded  ;  consequently  there  is  no  single 
psychological  test  of  this  condition.  Deficiency  of  some  kind  or 
other  is  always  present  irTTheTiighest  mental  faculties,  but  the 
nature  of  this  is  subject  to  considerable  variation.  In  many 
persons  there  is  an  utter  inability  to  acquire  any  kind  of  book- 
learning,  although  they  may  use  their  hands  with  considerable 
dexterity.  On  the  other  hand,  there  are  those  who  possess  a 
remarkable  aptitude  for  acquiring  certain  forms  of  knowledge, 
but  who  are  so  simple  and  childish  as  to  be  iitterly  incapable  of 
providing  for  their  daily  wants.  Others,  again,  as  will  be  seen 
in  treating  of  moral  defectives,  have  a  degree  of  cunning  and 
intellectual  quickness  of  a  certain  order  which  is  at  times  astonish- 
ing ;  whilst  yet  others  are  stolid,  indifferent,  and  entirely  negative. 
It  is  thus  seen  that  mental  defect  cannot  be  looked  upon  as  simply 
a  lower  grade  of  the  normal,  but  as  a  fli<stinrt1y  pathol^gicaj  con- 
dition in  which  detective  is  accompanied  by  irregular  ^pyq]op-_ 
ment.  Considered  from  the  standpoint  01  practical  daily  life, 
the  essential  characteristic  of  this  class  is  that,  whereas  the 
ordinary  person,  whether  quick  or  dull  witted,  profits  by  his 
experience,  and  learns  bit  by  bit  to  take  care  of  himself  and  to 
adapt  his  behaviour  to  the  exigencies  of  the  moment,  the  feeble- 
minded person  does  not.  The  de^ectiii£..ai]Lduiregular_develop- 
m^ent  oLhis  mind  have  combined  to  bring  about  a  lack  of  that 
quality  which  is  so  hard  to  define,  and  yet  so  essential  to  success 
ijn  life—common  sens^.  In  any  doubtful  case,  therefore,  the 
diagnosis  must  rest  not  only  upon  the  examination  as  to  the 
present  meT^tal  attainments^  but  also  upon  a  careful  consideration 
of  the  previous^Jiifi-tory  and  general  conduct  of  the  individual.    -^ 


[•091    ?Sv4  30V/  OJ^ 


•lA  a-LV'M 


CHAPTER    X 

IMBECILITY 

Definition. — ^The  term  "  imbecility  "  (Latin  imbecillus,  doubt- 
fully derived  from  prefix  im  for  in,  and  bacillus,  a  staff — one  with- 
out a  stay  or  support,  hence  feeble,  helpless)  is  applied  to  the 
medium  grade  of  amentia  ;  and  although  there  are  many  mem- 
bers at  the  top  and  bottom  of  this  grade  whose  condition  closely 
approximates  to  the  feeble-minded  and  the  idiots  respectively, 
nevertheless  it  is  one  which,  as  a  whole,  has  tolerably  well-defined 
features.  The  imbeciles  stand  above  the  idiots  in  the  possession 
of  an  instinct  and  capacity  for  self-preservation,  but  below  the 
feeble-minded  in  their  inability  to  perform  sufficient  work  to  con- 
tribute appreciably  towards  their  support.  They  are  defined  as 
"  those  persons  who,  by  reason  of  mental  defect  existing  from  birth  or 
from  an  early  age,  are  incapable  of  earning  their  own  living,  but  are 
capable  of  guarding  themselves  against  common  physical  dangers.'' 

Number. — I  estimate  the  total  number  of  imbeciles  existing  in 
England  and  Wales  on  January  i,  1906,  at  approximately  25,096 
persons,  corresponding  to  073  per  1,000  of  the  population.  The 
class  is  thus  nearly  half  as  numerous  as  the  adult  feeble-minded, 
and  abou^jthree  times  as  numerous  as  the  idiots.  The  inquiries 
of  the  Royal  Commission  show  that  imbeciles,  both  absolutely 
and  relatively,  are  more  prevalent  in  rural  than  in  urban  and 
industrial  areas. 

Sex. — There  is  a  slight^preponderance  of  the  male  sex,  and  out 
of  1,807  imbeciles  discovered  by  the  Royal  Commission  959  were 
males  and  848  females. 

Description. 

All  imbeciles  come  within  the  terms  of  the  definition  just  given, 
in  that  they  are  possessed  of  wit  sufficient  to  understand  and 
avoid  the  common  physical  dangers  which  threaten  life,  but 

159 


I 


160  Mental  Deficiency 

Jnsufficient  to  enable  them  to  pursue  any  continuous  occupation 
in.  such  a  manner  as  to  provide  for  their  sustenance.  "But  whilst 
they  all  agree  in  these  common  characteristics,  a  certain  propor- 
tion present  such  marked  physiognomical,  and  often  mental, 
peculiarities  as  to  form  distinct  clinical  varieties.  These  varieties 
will  be  described  in  subsequent  chapters,  the  general  account 
which  will  here  be  given  of  imbeciles  and  idiots,  as  also  the  pre- 
ceding account  of  the  feeble-minded,  referring  to  the  simple  type 
(the  '"genetous  "  group  of  Ireland),  to  which  the  great  majority 
of  these  persons  belong.     (See  Chapter  V.,  ''Classification.") 

Physical  Condition. — In  a  small  number  of  persons  suffering 
from  imbecility  of  the  secondary  form  (in  which  the  defect  is 
accidental  and  symptomatic 'of  some  acquired  disease  of  the 
brain),  the  features,  stature,  and  general  bodily  development 
may  not  differ  from  those  of  a  healthy  pefrson.  But  these  cases 
are  not  numerous,  and  in  the  great  majority  of  simple  imbeciles 
of  the  primary  form  the  bodily  as  well  as  the  mental  condition  is 
obviously  defective. 

Occasionally  gigantism  is  seen,  but  as  a  rule  the  stature  is 
several  inches  less  thanj^iat  of  the  nqrnial  person.  In  addition, 
the  body  is  ill-formed,  its  balance  and  carriage  are  ungainly, 
there  are  many  oddities  of  walk  and  bearing,  whilst  stigmata  of 
degeneracy  are  both  nurnerous  and  prominent.  The  expression 
of  the  imbecile  is  usually  in  itself  sufficiently  striking  to  attract 
attention,  varying  from  a  stolid  vacuity  to  a  fatuous  and  childish 
smile  or  a  look  of  sly  cunning.  Disturbances  of  physiological 
function  are  common.  Various  degrees  of  paralysis  occur  in  a 
certain  proportion  of  cases,  and  probablvabgut  40  per  cent,  of  all^ 

^imbeciles  suffer  from  epilepsy.  On  the  whole,  the  bodily  con- 
dition is"  so  distinctive  that  even  the  casual  observer  has  little 
difficulty  in  dubbing  one  of  this  class  a  "  daftie  'j,^r-^Uiatur«l." 
(See  Plates  VL,  VII.,  and  VIIL)  ^-""^ 

Mental  and  Nervous  Condition. — In  some  imbeciles  one  or  more 
senses  are  markedly  defective  ;  in  others  there  is  an  increased, 
and  even  extraordinary,  delicacy  \)i  a  particular  sense  ;  in  the 
majority,  however,  sensory  percept  on  is  obtuse,  and  a  condition 
similar  to,  but  decidedly  more  aggravated  than,  that  in  the 
feeble-minded  is  present.  The  teni  city  of  memory  for  isolated 
events  does  not  appear  to  be  diminished,  but  the  range  of  memory 


Imbecility  i6i 

is  decidedly  jnferioLtgthat  of  the  normal  person.  Probably  this 
is  largely  the  result  of  a  defective  power  of  association.  Spon- 
taneous attention  is  sometimes  diminished.  Although  many  of 
these  persons  can  be  habituated  to  perform  routine  work  of  a 
simple  kind,  they  are  quite  incapable  of  any  task  necessitating  a 
sustained  effort  of  voluntary  attention.  A  few  of  the  milder 
types  show  some  evidence  of  imagination,  but  the  majority  are 
lacking  in  this  faculty.  Where  the  feeble-minded  person  will 
invent  plausible  excuses  to  escape  punishment  for  his  misdeeds, 
the  imbecile  will  simply  lie  without  embroidery.  Many  have 
some  capacity  for  imitation,  and  at  times  this  may  be  educated 
sufficiently  to  enable  them  to  perform  a  certain  amount  of  useful 
work  ;  but  they  readily  tire,  and  in  most  cases  the  value  of  the 
work  done  is  not  worth  the  supervL  ion  it  entails.  Occasionally  the 
imbecile  is  markedly  defective  in  v  ilition,  but  this  is  by  no  means 
always  the  case,  for  some  of  these  persons  have  exceedingly 
strong  desires,  and  are  capable  of  no  little  strength  and  cunning 
to  obtain  their  ends.  It  is  often  easier  to  lead  than  to  drive 
an  imbecile,  and  some  of  them  are  particularly  amenable 
to  suggestion.  It  is,  however,  in  reasoning  capacity  that 
the  most  marked  difference  is  seen  between  this  class  and  the 
feeble-minded.  The  latter  person,  although  very  defective,  is 
still  capable  of  simple  mental  comparisons,  and  of  arriving  at 
simple  judgments  ;  but  the  imbecile  is  usually  quite  incapable 
of  this. 

Abnormalities  of  movement  are  of  very  common  occurrence. 
In  the  apathetic  type  there  is  a  general,  diminution,  whilst  in 
those  of  the  excitable  form  all  movement  tends  to  be  excessive. 
These  excitable  imbeciles  are  constantly  chattering,  running 
about,  and  generally  interfering  with  everybody  and  everything. 
Some  of  them  are  violently  aggressive,  and  a  few  become  actually 
insane.  Defects  of  ci^-ordination  are  both  commoner  and  more 
pronounced  than  in  the  feeble-minded.  Most  imbeciles  can 
speak,  although  they  can  only  form  simple  sentences,  and  their 
vocabulary  is  a  meagre  one.  The  development  of  the  faculty  of 
speech  is  invariably  late.  A  few  are  exceedingly  voluble  in  con- 
versation, but  the  matter  is  (  hildish  and  inconsequent.  Defects 
of  pronunciation  are  numero  s.  Some  imbeciles  can  read  simple 
sentences,  and  a  few  learn  to  add  and  subtract  upon  their  fingers, 

II 


1 62  Mental  Deficiency 


or  by  means  of  beads,  but  the  scholastic  acquirements  of  the  class 
as  a  whole  are  of  a  very  low  order. 

Like  the  feeble-minded,  imbeciles  are  divisible  into  two  chief 
types — the  apathetic  or  stable  and  the  excitable  or  unstable. 
Accordingly,  they  differ  greatly  in  their  disposition  and  general 
behaviour.  Some  are  harmless,  inoffensive,  and  well-behaved  ; 
but  others  are  just  the  reverse,  and  require  to  be  under  constant 
observation.  These  latter  are  often  sly  and  cunning  to  a  degree, 
always  in  trouble,  and  possessed  of  pronounced  immoral  and  anti- 
social tendencies.  Some  are  clean  in  habits,  modest,  and  possess 
a  tolerable  sense  of  decency  ;  others  are  absolutely  destitute  of 
any  idea  of  shame  or  modesty.  Masturbation  is  very  frequent 
in  imbeciles  of  both  sexes,  and  many  of  them  will  practise  it  in 
the  most  open  and  outrageous  manner.  Some  imbeciles  show 
unmistakable  signs  of  jeaipusy,  and  a  considera/blejrunib^£_are 
exceedingly  vain,  not  only  of  tHeif  HfeSS^nd  general  appearance, 
but  even  of  their  mental  attainments. 

The  following  cases  illustrate  the  chief  features  of  simple 
imbecility  : 

C.  H.,  a.  fat,  smiling  man,  forty  years  of  age,  who  has  been  in 
the  asylum  since  boyhood.  He  has  no  friends  living,  and,  beyond 
a  note  in  the  ca^e-book  to  the  effect  that  there  is  insanity  on  the 
father's  side,  there  are  no  particulars.  He  understands  and  can 
carry  on  a  simple  conversation,  but  he  cannot  read  or  write,  and 
has  no  conception  of  figures.  He  can,  however,  appreciate  pic- 
tures, and  will  laugh  immoderately  at  anything  funny.  He  is 
good-tempered  and  obedient,  but  a  perfect  glutton,  and  will 
devour  any  scraps  he  comes  across.  He  is  too  defective  to  be 
entrusted  with  any  work  without  supervision,  but  is  very  willing 
and  spends  most  of  his  time  with  the  gardener  in  the  grounds. 

/.  F.,  male,  twenty  years  old,  is  the  last  born  of  a  family  of 
seven,  of  whom  three  died  in  early  childhood  (one  of  convul- 
sions);  two  are  said  by  the  mother  to  be  "all  right,"  whilst 
another  is  mentally  defective.  The  father  is  alive,  but  has  been 
insane  in  an  asylum  twice  ;  one  of  his  brothers  died  in  an  asylum. 
The  mother  is  alive,  but  in  delicate  health.  Two  of  her  sisters 
and  one  brother  died  of  consumption. 

James  has  always  been  "delicate"  ;  he  did  not  stand  until 
turned  two  years,  and  did  not  walk  until  his  fourth  year.    He  was 


Plate  VII. 


£2 


-SH 


.2  nJ 


^ 


0)      . 

...  c 

0)  -iJ 


Tt?  yac^  />a£-e  162. 


"V 


Imbecility  163 

over  five  before  he  spoke,  and  even  now  his  vocabulary  is  Hmited 
to  about  a  dozen  words.  These  he  uses  very  sparingly,  and  it 
is  rarely  that  he  can  be  got  to  reply  to  questions,  although  he 
understands  a  good  deal  of  what  is  said  to  him.  He  never 
attended  school,  as  the  head-mistress  refused  to  have  him.  He 
remained  at  home  quite  unoccupied  until  fifteen  years  of  age, 
when  he  became  unruly  and  more  than  his  mother  could  manage. 
Since  then  he  has  been  in  the  asylum. 

He  is  a  short,  stumpy,  fat  youth,  with  coarse  features,  large 
outstanding  ears,  and  a  typical  imbecile  expression.  He  has  a 
high  saddle -shaped  palate  and  very  irregular  and  malformed 
teeth ;  but  these  cannot  always  be  demonstrated,  as  he  usually 
obstinately  refuses  to  open  his  mouth.  Cranial  circumference, 
22  J  inches.  There  is  no  paresis,  but  he  is  clumsy  and  heavy  in 
all  his  movements.  There  is  no  marked  defect  of  the  special 
senses,  but,  owing  to  his  usually  taking  not  the  slightest  notice 
of  any  question  addressed  to  him,  he  has  been  thought  to  be 
deaf.  This,  however,  is  not  the  case,  as  I  have  succeeded  in 
getting  him  to  turn  round  at  the  sound  of  a  whistle,  and  have 
once  or  twice  managed  to  get  him  to  execute  a  simple  com- 
mand. He  seems  to  have  little  idea  or  care  as  to  where  he  is,  is 
apparently  unconscious  of  the  flight  of  time,  and  is,  as  a  rule, 
perfectly  stolid  and  inoffensive.  But  occasionally  he  has  a  noisy 
outbreak,  and  then  he  will  rush  about  the  ward  grunting,  yelling 
and  interfering  with  anyone  whom  he  meets.  I  saw  him  one 
day  munching  biscuits  out  of  a  paper  bag  which  had  been 
brought  him  by  his  mother.  I  intercepted  each  biscuit  on  its 
way  from  the  bag  to  his  mouth.  He  did  not  seem  to  mind,  and 
placidly  got  another  out  of  the  bag.  When  I  had  succeeded  in 
getting  them  all,  he  stood  still  in  a  vacant,  perplexed  sort  of  way, 
without  seeming  to  understand  or  care  very  much,  and  after  a 
lime  he  walked  away. 

H.  C,  female,  seventeen  years  ;  is  the  fourth  of  a  family 
of  eight,  three  of  whom  died  in  infancy ;  insanity  and  epilepsy 
on  father's  side.  No  others  are  mentally  affected,  but  mother 
says  they  are  all  delicate.  The  patient  never  seemed  the  same 
as  the  other  children  from  birth,  and  did  not  walk  until  her 
fourth  year.     She  has  never  talked  properly. 

She  went  to  school  for  several  years,  but  never  learned  any- 

II— 2 


164 


Mental  Deficiency 


thing,  and  finally  the  mistress  said  she  had  better  not  come  any 
more.  She  has  since  been  at  home'  She  understands  a  good 
deal  of  what  is  said  to  her,  and  can  execute  simple  commands, 
such  as  to  shut  the  door  or  fetch  a  chair.  She  can  answer  simple 
questions  in  monosyllables,  but  her  articulation  is  so  defective 
as  to  be  unintelligible  to  a  stranger.  She  has  no  idea  of  number, 
and  everything  is  "  two."  She  has  no  knowledge  of  letters,  but 
can  make  strokes  and  ciphers  on  a  slate.  She  also  knows  the 
names  of  the  common  objects  of  the  house.  On  the  whole,  she 
is  quiet,  obedient,  and  good-tempered.  She  is  not  actively 
destructive,  but  will  always  pick  a  patch  off  her  clothes  if  they 
have  been  mended,  and  her  chief  joy  is  to  have  a  piece  of  cloth 
given  her  to  fray  out.  She  cannot  wash  or  dress  herself,  but 
can  feed  with  a  spoon,  and  is  of  clean  habits.  Her  chief  pecu- 
liarity seems  to  be  that,  as  soon  as  she  takes  the  first  mouthful 
of  food,  she  invariably  goes  to  sleep,  and  has  to  be  wakened  to 
finish  her  meal. 


Plate  VIII. 


To  f  ice  page  164.] 


>>" 


CHAPTER  XI 

IDIOCY 

Definition. — In  the  idiots  we  see  the  third  and  lowest  degree  of 
defect,  and  the  mental  deprivation  in  these  persons  is  indeed  such 
as  to  fuUy  justify  the  term  idios  (  a  person  "  private.,"  "  apart," 
or  "  solitary  ")  which  is  applied  to  them. 

The  Hne  between  this  class  and  the  imbeciles  has  been  variously 
drawn  by  different  writers.  Some  would  consider  the  presence 
or  absence  of  speech  as  the  criterion,  but  there  are  many  imbeciles 
— and  even  feeble-minded — who  cannot  speak.  Others,  again, 
would  use  attention  or  volition,  but  these  are  not  necessarily 
lacking  in  the  idiot.  If  a  Une  is  to  be  drawn,  and,  if  only  for 
purposes  of  description,  it  is  clearly  a  great  advantage  that  we 
should  have  some  means  of  differentiation,  then  I  think  that  the 
absence  of  the  instinct  or  power  of  self-preservation  constitutes 
the  most  convenient  one,  and  this  we  shall  accordingly  use. 

The  idiot  is  therefore  defined  as  "  a:  person  so  deeply  defective 
in  mind  from  birth,  or  from  an  early  age^that  he  is  unable  to  guards 
himself  against  common  physical  dangers.'' 

Accepting  this  as  the  criterion,  it  is  at  once  seen  that  idiots 
are  divisible  into  two  groups.  In  one  of  these  the  defect  is  so 
profound  as  to  involve  the  fundamental  organic  instincts,  and 
even  that  of  sucking  is  absent.  These  are  termed  complete, 
ah^olute,  ovprofound  idiots.  In  the  second  group  tTie~primitive 
instincts  are  present — ^there  is  even  some  glimmering  of*  mind — 
but  there  is  not  sufficient  intelligence  to  understand  and  avoid 
the  common  physical  dangers  which  threaten  existence.  These 
may  be  termed  the  partial  or  incompleteidiots. 

Number. — ^The  mlmbei  Of  idioLs  existing  in  England  and 
Wales  on  January  i,  1906,  was,  approximately,  8,654  persons, 

165 


1 66  Mental  Deficiency 

corresponding  to  0*25  per  thousand  of  the  entire  population. 
The  class  is  thus  about  one-third  as  numerous  asjtheJmbeciles, 
and  comprises  about  6  per  cent,  of  all  aments.  As  we  have 
already  seen,  idiots  are  absolutely  and  relatively  much  more 
numerous  in  rural  than  in  urban  di^trjr.t.g;^  and,^aking  areas  with 
a  sinnlaiLincidence  of  total  amentia,  we  find  that  there  are  ofteiT 


froqijomJo^^fr^^Tiine^  inl:he  jofmer  as  __ 

in  the  latter  situation.  A  similar  variation  of  incidence  with 
regard  to  environment  has  been  shown  to  obtain  with  the  imbe- 
ciles also,  but  the  disproportion  is  much  greater  in  the  case  of  the 
idiots. 

With  regard  to  sex,  the  inquiries  of  the  Royal  Commission  show 
that,  of  585  idiots  existing  in  the  16  areas  of  the  United  Kingdom 
which  were  investigated,  there  were  303  males  and  282  females. 

Description. 

Partial  or  Incomplete  Idiocy.  —  Physical  Condition.  —  The 
various  anatomical  and  physiological  anomalies  present  in  the 
imbeciles,  and  to  a  somewhat  less  extent  in  the  feeBle^-rhinded, 
reach  their  maximum  in  the  idiots  ;  and  the  membery  61  Lhis"" 
degree~conSeqnently  present  an  appearance  which  is  in  itself 
distinctive.  Some  of  them  are  grotesque,  but  the  majority  are 
such  stunted,  misshapen,  hideous,  and  bestial  specimens  of 
morbid  mankind  that  they  arouse  feelings  of  horror  and  repul- 
sion rather  than  of  levity.     (See  Plates  IX.  and  X.)     Paresis  or 

paralysis  is  very  often  present,  and  this  tends  still  further  to  aggra- 
vate their  defective  physical  condition.  In  some  cases  this  para- 
lysis is  due  to  a  non-development  of  the  tracts  of  the  cord  ;  but 
in  the  majority  it  is  the  result  of  dis£age  or.s£yere  gross  Igsion^of 
theJbj^in  .or_nervous  system  superadded  toJLhe  original  develop- 
mental  defect,  such  as  porencephaly,  hydrocephaly,  micro- 
gyria, localized  atrophies,  and  anomalies  of  the  internal  ganglia. 
The  paralysis  may  be  slight  or  severe.  It  may  involve  a  hand 
or  foot,  or  be  a  complete  hemiplegia  or  diplegia.  Many  of  these 
creatures  are  in  consequence  chair-  or  bed-ridden.  Occasion- 
ally the  condition  known  as  "  scissor-legs  "  is  seen,  in  which 
there  is  paralysis  of  both  lower  limBs,  with  dislocation  of 
the  hip-joints,  so  that  the  legs  are  permanently  crossed  like  a 


Plate  IX. 


u 


CO 


a, 
< 


To  face  page  i66. 


■-■-■^-:^ 


Idiocy  1 67 

pair  of  scissors.  There  was  a  very  perfect  example  of  this  at 
Darenth  Asylum  a  few  years  ago.  The  feature  of  most  of  these 
paralyses  is  that  they  are  the  result  of  lesions  occurring  before  or 
shortly^ aftgr  birth  ;  consequently  the  liinb_in\:olved  is  stunted  in 
ijs_gro  wt  h_a^n  d  development."^      ^     " , 

Epilep&v  is  very  frequent  in  simple  idiots,  and  occurs  in  about 
56  per  cent,  of  cases  ;  various  forms  of  tremor  and  athetosis  are 
also  frequently  seen. 

Many  idiots  are  extraordinarily  voracious,  and  gulp  down  their 
food  with  such  haste  as  to  be  in  imminent  danger  of  choking. 
It  has  more  than  once  happened,  where  spoon  diet  has  not  been 
given,  that  tracheotomy  has  had  to  be  performed  for  the  removal 
of  a  lump  of  food  from  the  larynx.  In  a  few  cases  rumination 
is  seen.  Troublesome  diarrhoea  is  a  very  common  result  of  the 
gluttony  of  these  persons.  Ireland  mentions  two  cases  in  which 
inordinate  thirst  was  present,  the  patients  drinking  almost  any 
kind  of  liquid  in  enormous  quantities  ;  neither  was  diabetic. 

Most  idiots  are  sterile,  but  this  is  not  always  the  case,  and  in 
some  sexual  feelingsare  obtrusively  evident.  As  a  class  they  are 
unusually  prone  to  disease  and  to  early  death,  particularly 
from  tuberculosis. 

Mtvital  luid  Xervous  Condition. — Defects  of  sensation  are  very 
common  in  idiots,  and  although  morbid  conditions  of  the  end- 
organs  of  special  sense  are  very  frequent,  nevertheless  the  lack 
of  perception  seems  to  be  more  often  due  to  a-G€ntral._.than  to  ji^ 
ppTiphfTal  rjefert.  All  the  senses  may  be  affected,  but  it  usually 
happens  that  one  is  most  so.  We  thus  find  some  idiots  particu- 
larly impervious  to  sounds,  others  to  sights,  tastes,  or  odours. 

It  is  difficult  to  test  the  memory  of  these  persons,  but  on  the 
whole  I  am  inclined  to  think  that  it  is  usually  in  default. 
Imagination  seems  to  be  wanting  altogether,  but  some  of  the 
milder  types  have  a  certain  capacity  for  imitating  the  actions  of 
those  around  them.  Active  attention  is  very  deficient,  but  spon- 
taneous attention  is  by  no  means  always  absent.  Such  thoughts 
as  exist  must  be  of  the  simplest  description,  and  limited  to 
objects  immediately  present  to  their  senses.  They  have  no  power 
of  reasoning,  and  although  a  few  can  connect  simple  words 
with  the  objects  to  which  they  relate,  the  majority  cannot  do 
this.     Idiots  have  to  be  washed,   dressed,  and  fed  like  little 


1 68  Mental  Deficiency 

children  ;  many  of  them  are  utterly  inattentive  to  the  calls  of 
nature,  but  some  can  be  taught  habits  of  regularity  and  cleanli- 
ness in  this  respect.  They  are  by  no  means  lacking  in  energy 
and  volition,  and  many  of  them  apparently  experience  satisfac- 
tion in  destroying  anything  they  can  get  hold  of  ;  but  their  energy 
cannot  be  directed  into  any  useful  channel,  nor  are  they  even 
capable  of  intelligent  play. 

Tears  are_^yery  rarely  seen,  but  there  is  no  doubt  that  some 
of  milder  degree  are  capable  of  the  simpler  emotions.  They 
evince  anger,  passion,  and  fright,  and  some  of  them  will  run 
away  with  a  look  of  alarm  upon  the  entrance  of  a  stranger. 
They  seem  to  be  absolutely  lacking  in  any  sense  of  right  or 
wrong,  and  these  ideas  cannot  be  implanted  in  them. 

Speech  is  usually  absent,  although  a  few  learn  to  articulate 
such  simple  monosylfeWes  as  man,  cat,  eat,  etc.,  but  noneol  them 
can  form  sentences.  Their  utterances  mostly  consist  of  m- 
af^iculate  grunts,  screeches,  and  discordant  yellsj  but  there  can 
be  no~Houbt  that  these  often  express  their  feelings,  just  as  do 
the  cries  of  animals,  and  an  observant  physician  or  attendant  is 
able  by  this  means  to  discern  whether  they  are  satisfied  or  dis- 
satisfied, contented  or  annoyed,  sometimes  even  to  interpret 
their  simple  wants.  It  is  noteworthy  that,  although  quite 
unable  to  articulate,  some  idiots  will  hum  a  tune  which  they  have 
heard,  with  tolerable  accuracy. 

Movement  is  often  abnormal  .in  quantity  and  _quahty.  In 
the  apathetic  type  of  idiots  it  is  deficient,  in  the  excitable  ex- 
cessive. In  both  these  forms  co-ordination  is  usually  very 
imperfect,  and  they  are  hardly  ever  capable  of  any  delicacy  of 
manipulation.  In  standing,  walking,  or  running  the  same 
defect  of  co-ordination  is  seen. 

.^^ESlllfitic  and  Excitable  Idiots. — We  have  seen  that  the  less- 
pronounced  grades  of  defect  are  divisible  into  two  classes  accord- 
ing as  they  are  of  stable  or  unstable  mental  equilibrium  ;  the 
same  is  true  of  the  idiots,  some  of  these  being  apathetic,  and 
others  excitable.  The  former  are  mild,  placid,  inoffensive 
creatures  who  give  little  trouble,  and  who  even  evince  a  certain 
amount  of  affection  for  those  who  feed  and  attend  to  them. 
The  excitable  type,  on  the  other  hand,  are  passionate,  violent, 
untrustworthy,  and  intractable.     Many  of  them  are  so  exceed- 


Plate  X. 


To  face  page  i68.] 


Idiocy  169 

ingly  destructive  that  nothing  is  safe  within  their  reach.  They 
will  destroy  clothes,  toys,  picture-books,  even  furniture,  and 
if  left  alone  for  a  few  hours,  the  probability  is  that  they  will  either 
wreck  the  room  or  set  fire  to  or  seriously  injure  themselves  in 
some  way.  I  have  seen  several  of  this  class  in  cottages  where 
the  only  available  means  of  curtailing  their  activities  to  a  reason- 
able sphere  of  influence  was  to  tether  them  to  the  table  leg. 
Often  they  are  exceedingly  cruel  to  animals,  and  seem  to  ex- 
perience pleasure  at  the  cries  of  their  unfortunate  victims. 

Those  of  this  type  who  are  chair-ridden  still  manage  to 
find  an  outlet  for  their  excitability  in  the  almost  ceaseless  per- 
jpnnance  of  automatic  actions.  Thus,  some  will  spend  the  day 
turning  the  head  from  side  to  side  or  nodding  up  and  down  ; 
others  rock  the  body  to  and  fro,  or  beat  upon  the  chest  with 
the  hand,  often  keeping  time  to  the  movement  with  a  mono- 
tonous, inarticulate  chant  ;  others  unceasingly  suck  their 
fingers.  T^se  movements  do  not  occur  during  sleep,  and  they 
are  terminated  by  the  advent  ot  leeding-irhue  ur"thg~^ntfy  of  a 
stranger,  although  at  times  a  visitor  seems  to  stimulate  them 
into  still  more  violent  activity.  It  is  evident  that  they  are 
attended  with  satisfaction,  for  the  patients  commonly  resent 
forcible  interruption,  and  resume  the  movements  again  the 
moment  they  are  free.  In  a  proportion  of  cases  this  condition 
of  restless  activity  is  not  constant,  but  intermittent,  and  resembles 
the  periodical  outbreaks  of  maniacal  excitement  which  occur  in 
the  milder  aments.  Such  persons  will  rush  about  the  room  or 
dormitory  uttering  hideous  screeches  and  yells.  In  moments 
of  passion  they  will  even  hurl  themselves  violently  against  walls 
or  floor,  and  in  so  doing  often  sustain  serious  injuries.  But  the 
process  seems  to  be  rather  pleasurable  than  painful.  Even  in 
those  of  tJifiLapa-thetic  type,  the  advent  of  puberty  often  ushers 
in  a  maTked__altera^n„of  character  and  behaviour,  and  there 
are  many  idiots  who,  having  been  fairly  manageable  and  in- 
offensive until  this  time,  then  become  so  destructive  and  un- 
reliable that  the  restraint  of  an  institution  has  to  be  sought. 

The  following  are  illustrative  cases  : 

E.  J.,  female,  age  thirty-two  years.  A  pronounced  history  of 
insanity  and  epilepsy  on  the  maternal,  and  alcoholism  on  the 
paternal,  side.     Has  been  in  the  asylum  since  seven  years  of 


170  Mental  Deficiency- 

age.  A  repulsive-looking  woman  with  a  muddy,  freckled  face, 
coarse  red  hair,  and  numerous  stigmata  ;  cranial  circumference, 
21  inches.  She  can  walk,  but  spends  the  day  sitting  in  a  chair 
turning  her  head  from  side  to  side,  rocking  herself  to  and  fro, 
and  biting  her  hands.  She  is  of  unclean  habits  and  is  unable  to 
do  anything  for  herself.  She  is  quite  deaf  in  the  right  ear,  but 
listens  attentively  to  the  ticking  of  a  watch  held  close  to  her 
left.  She  seems  to  have  no  knowledge  of  time  or  place,  and 
apparently  no  understanding  of  anything  said  to  her.  But 
when  the  piano  is  played,  she  at  once  ceases  her  rhythmic  move- 
ments and  listens  attentively.  She  cannot  speak,  but  she  will 
hum  the  tunes  she  has  heard  so  well  that  they  are  readily  recog- 
nized. As  a  rule  she  is  harmless,  but  upon  any  attempt  at 
examination  she  makes  violent  resistance  and  tries  to  bite, 
and  she  is  at  times  spiteful  and  interferes  with  the  other 
patients. 

A.  D.  P.,  female.  Has  been  in  the  institution  since  childhood, 
but  the  family  history  is  not  obtainable,  as  there  are  no  friends 
living.  On  admission  she  was  unable  to  dress  or  feed  herself, 
and  had  no  apparent  unde-rstanding  of  anything  said  to  her. 
She  showed  no  curiosity,  no  imitativeness,  and  no  power  of 
attention.  Her  habits  were  unclean,  and  she  was  constantly 
dribbling  from  her  mouth.  She  was  a  voracious  eater.  She 
was  unable  to  speak,  but  addicted  to  violent  yells,  often  inter- 
spersed with  a  peculiar  sound  like  the  braying  of  a  donkey. 
She  was  at  times  exceedingly  violent,  kicking,  biting,  and 
scratching  the  nurses  and  other  patients  indiscriminately,  and, 
in  fact,  was  generally  a  source  of  endless  trouble  to  the  whole 
ward.  She  remained  in  practically  the  same  condition  until 
thirty-five  years  of  age,  when  she  had  an  epileptic  attack.  From 
this  time  until  her  death  she  was  subject  to  occasional  recurrences 
of  the  fits,  and  she  died  at  the  age  of  thirtyrsix,  of  gangrene  of 
the  lung,  resulting  from  the  aspiration  of  a  small  portion  of  food. 
The  cranial  circumference  was  20  inches,  and  there  were  numer- 
ous stigmata  of  degeneracy. 

On  making  a  post-mortem  examination,  I  found  a  very  thick, 
dense  skull  with  an  absence  of  diploe.  The  brain  was  small, 
weighing  1,022  grammes,  but,  beyond  being  very  simply  con- 
voluted,   there   were   no   naked-eye   anomalies,     Microscopical 


Idiocy  171 

examination,  however,  revealed  extensive  imperfections  of  the 
cells  of  both  brain  and  spinal  cord  like  those  already  described. 

Absolute,  Complete,  or  Profound  Idioqy. — In  this  condjlion  we 
see  humanity  reduced  to  its  lowest  possible  expression.  Although 
Thesf  unfortunate  creatures  are,  indeed,  the  veritable  offspring 
of  Homo  sapiens,  the  depth  of  their  degeneration  is  such  that 
existence — for  it  can  hardly  be  called  life — is  on  a  lower  plane 
than  even  the  beasts  of  the  field,  and  in  many  respects  may  almost 
be  described  as  vegetative.  They  come  into  the  world  without 
even  the  hereditary  instinct  of  sucking.  As  they  grow  up  they 
have  to  be  fed,  and  would  die  of  inanition  amid  abundance  of 
food  were  it  not  put  into  their  mouths.  If  they  are  conscious 
of  excessive  heat  or  cold,  they  are  devoid  of  any  idea  of  the 
rei!Tedy. — They  respire,  assimilate,  and  excrete,  but  they  have 
no  sexual  instinct,  and  cannot  reproduce  their  degenerate 
species.  They  may  be  capable  of  inarticulate  cries,  but  they 
cannot  speak.  They  possess  the  power  of  muscular  movement, 
but  locomotion  is  "Sl^sent.'  They  have  eyes,  but  they  see  not  ; 
ears,  but  they  hear  not  ;  they  have  no  intelligence  and  no  con- 
sciousness of  pleasure^or  pain  ;  in  fact,  their ntental  state  is  one 
entire  negation.  The  short  existence  of  most  of  these  creatures  is 
spent  in  bed,  where  they  lie  huddled  up  in  an  ante-natal  posture. 
They  are  hideous,  repulsive  creatures  whom  Nature  permits  to 
enter,  but  not  to  Unger,  in  the  world,  and  in  their  life  and  death 
are  revealed,  the  culminating  and  final  manifestation  of  the 
neuropathic  diathesis.  "'""^ '"  ' '    ^"'     — — 

Diagnosis. — ^The  diagnosis^ofjimple  idiocy  and  imbecility  can 
rarely  present  much  difficulty  by  the  time  the  child  has  attained 
to  the  age  of  five  or  six  years.  Even  before  that  age,  a  careful 
c(5hsideration  of  the  family  history,  of  the  general  backwardness 
of  development,  and  of  the  many  indications  of  defective  physical, 
nervous,  and  mental  condition  which  should  be  apparent  to 
the  physician,  although  they  may  not  be  noticed  by  the  parents, 
will  usually  suffice  to  make  the  nature  of  the  case  quite  clear. 
The  idiot  or  pronounced  imbecile  is  usually  either  phenomenally 
passive  or  abnormally^  restless  frOm  the  first  few  days  after  birth. 
In  the  one  case  he  is  inert,  showing  no  tendency  to  suck  or  grasp. 


1/2  Mental  Deficiency 

so  that  even  the  nipple  must  be  held  in  his  mouth  ;  no  tendency 
to  cry  or  to  be  attracted  by  any  sight  or  sound  ;  no  response  to 
the  caresses  of  his  mother  ;  and,  in  fact,  no  spontaneity  of  any 
description.  In  the  other  case  he  is  constantly  crying,  and 
refuses  to  be  pacified  ;  he  restlessly  tosses  about  from  side  to 
side  in  his  cot,  and  from  time  to  time  may  have  convulsions. 
In  some  of  these  cases  the  screaming  and  general  rest- 
lessness are  so  constant  that  the  parents  will  complain  that 
the  child  never  sleeps.  With  either  of  these  conditions  there 
are  usually  present  various  anomalies  of  anatomical  develop- 
ment, and  although  I  do  not  mean  to  say  that  the  combination 
of  stigmata  with  one  or  other  of  these  unnatural  states  is  patho- 
gnomonic of  amentia,  nevertheless  it  is  extremely  suggestive 
of  that  condition,  and  the  probability  is  greatly  increased  should 
there  be  a  neuropathic  family  history.  Careful  attention  to 
these  points  will  often  enable  a  diagnosis  to  be  made  in  the  first 
or  second  year,  and  should  prevent  the  physician  deluding  the 
parents  with  the  vain  hope  that  the  child  will  "  grow  out  of  it." 
With  the  advance  of  each  year  the  nature  of  the  case  becomes 
more  obvious,  for  the  progressive  mental  development  of  the 
normal  child  gradually  leaves  the  ament  farther  and  farther 
behind. 

Where  some  added  complication  or  particular  pathological 
process  is  present,  as  in  the  special  varieties  of  amentia  to  be 
described  in  subsequent  pages,  the  clinical  appearance  is  still 
more  characteristic,  and  a  diagnosis  may  then  be  possible  at  an 
even  earlier  age. 


CHAPTER  XII 

THE  CLINICAL  VARIETIES  OF  PRIMARY  AMENTIA 

It  is  probable  that  nearly  90  per  cent,  of  all  aments  belong  to 
the  primary  group,  and  the  majority  of  these,  as  already  men- 
tioned, present  no  special  distinguishing  features  beyond  the 
anatomical,  physiological,  and  psychological  anomaUes  common 
to  primary  aments  in  general.  These,  which  may  be  termed 
the  simple  variety,  have  been  described  in  the  preceding  pages. 

A  small  proportion,  however,  present  such  special  character- 
istics as  to  form  distinct  clinical  types.  The  chief  of  these  are 
the  Microcephalics  and  Mongolians,  and  these  will  be  described 
^  the  present^^hapter.  We  shall  also  briefly  deal  with  some 
clinical  subvarieties  which  are  the  result  of  superadded  morbid 
compHcations. 

The  Grecian,  American-Indian,  Negroid,  and  other  ethnic  types 
which  have  been  described  by  some  authors  do  not  seem  to  me 
to  possess  sufficiently  distinguishing  features  to  merit  special 
notice. 

MICROCEPHALIC  AMENTIA. 

By  the  term  *'  microcephaUc  "  is  usually  meant  a  person  whose 
^kuU  is  less  than  17  inches  in  its  grf^ntflit  rirmrn^r^"^^  But  in 
view  of  thFfacTthat  other  persons,  with  a  greater  cranial  measure- 
ment than  this,  present  similar  mental  peculiarities  as  well  as 
skull  configuration,  I  am  disposed  to  think  that  the  criterion 
should  be  one  of  shape  rather  than  size.  Most  members  of  this 
^ariety  belong  to  the  more  pronounced  degrees  of  amentia,  and, 
if  the  test  of  measurement  be  the  one  adopted,  they  probably 
do  not  comprise  more  than  about  5  or  6  per  cent,  of  all  aments. 
If,  howevef7"the  milder  cases  be  included,  and  the  criterion  be 
that  of  cranial  shape,  this  number  is  considerably  increased,  and 

^73 


174  Mental  Deficiency 


probably  reaches  lo  or  12  per  cent.  Many  of  these  latter  are 
merely  feeble-minded. 

Causation. — ^The  condition  is  one  which  has  attracted  much 
attention,  particularly  from  anatomists,  and  two  views  have  been 
put  forward  as  to  its  causation.  The  first  of  these  is  that  it  is 
an  atavistic  variation  ;  the  second,  that  it  is  a  pathological  con- 
ditiondue  to~premature  closure  of  tlie  cranial  sutures. 

One  of  the  earhest  advocates  of  the  atavistic  theory  was  Charles 
Vogt,  of  Geneva,  who,  in  a  paper  published  in  1867,*  attempted 
to  show  that  microcephaly  was  a  reversion  to  a  prehuman  type. 
Many  cases  were  examined,  and  most  minute  dissections  made 
by  accomplished  anatomists  on  the  Continent  and  in  this  country. 
Conclusive  evidence  was  adduced  in  support  of  the  view,  and 
equally  conclusive  facts  in  denial  of  it.  It  was  at  a  time  when 
the  evolutionary  theory  was  attracting  widespread  attention, 
and  it  was  not  to  be  wondered  at  that  the  curious  appearance  of 
microcephalics  should  cause  them  to  be  looked  upon  as  instances 
of  a  reversion  to  a  simian  type.  It  is  unnecessary  to  enter  into 
the  pros  and  cons  of  the  argument  ;  it  is  sufficient  to  state  that 
the  fact  has  now  been  established,  as  a  result  of  many  examina- 
tions, that  microcephaly  is  not  an  atavistic  variation,  but  a 
pathological  condition,  and  that  these  persons,  although 
degenerate,  are  still  human.  """  ~ 

The  second  theory,  that  microcephaly  was  due  to  a  premature 
synostosis  of  the  cranium,  attracted  hardly  less  interest.  Bail- 
larger  f  seems  to  have  been  the  author  of  this  view,  and  he 
enunciated  it  on  the  strength  of  some  apparently  very  definite 
statements  by  the  mothers  of  microcephalic  children,  that  at 
birth  the  anterior  fontanelle  was  closed.  These  statements  were 
corroborated  by  Baillarger's  examination  of  some  cases  in  which 
synostosis  was  present.  But  it  has  since  been  found  that  many 
microcephalics  exist  in  whom  the  sutures  are  not  closed ;  in  fact, 
such  is  the  exception  rather  than  the  rule,  and  hence  this  theory 
is  now  discarded.     In  the  instances  in  which  bony  union  has 

*  C.  Vogt,  Geneva,  "  Memoires  sur  les  Microcephales  ou  Hommes 
Singes,"  1867.  On  this  subject  see  also  "  I  CervellideiMicrocefali,"  Professor 
Giacomini,  Turin,  1890  ;  also  an  excellent  chapter  in  Dr.  Ireland's  work. 

•f  Baillarger,  Gazette  Medicate  de  Paris,  1857,  p.  482  ;  also  Cruveilhier, 
"  Anatomie  Pathologique  Generale,"  Paris,  1876. 


Plate  XL 


To  face  pa^e  176] 


The  Clinical  Varieties  of  Primary  Amentia    177 

social   development   and   excellence  in   the  arts   with  a   mean 
average  brain  capacity  of  only  40*1  ounces. 

The  fact  is  that  intellect  is  dependent  upon  quality  as  well  as 
quantity  of  brain,  and  although  in  many  aments  a  quantitative 
defect  is  present,  there  is  always  a  qualitative  deficiency  also. 
Accordingly  it  results  that  even  in  microcephalics  there  is  no 
consTant  relation  between  size  of  brain  and  mental  capacity.  *~ 

Description. — Physical  Condition. — ^The  two  chief  cHnical  dis- 
tinguishing features  of  this  variety  of  amentia  are  the  pecuHar 
configuration  of  the  skull  and  the  (usually)  very  small  stature. 
*^s   a   result   of    the   cerebral   hypoplasia,  there   is   a  marked    \ 
deficiency  in  the  frontal  and  occipital  regions  of  the  cranium, 
which  in  consequence  shelves  away  in  a  curiously  "  sugar-loaf  " 
or  cone-like  manner.     This  shape,  by  some  termed  oxycephalic, 
is  always  present  in  microcephaly,  and,  taken  in  conjunction  with 
the  receding  chin,  gives  a  very  characteristic  and  bird-Hke  ap- 
pearance to  these  creatures.     (See  Plates  XI.,  XVIII.,  and  XIX., 
In  consequence  of  the  diminished  surface  of  bone  to  be  covered, 
the  scalp  is  nearly  always  extraordinarily  thick  and  redundant.       !/*• 
In  some  cases  it  is  permanently  thrown  into  a  series  of  deep  ^p^^ 
furrows  running  antero-posteriorly,  a  condition  which  was  first  ^^^^< 
described  in  this  country  by  Dr.  T.  W.  McDowall,*  and  which  f^*"^  ^ 
seems  to  be  confined  to  microcephales.f     In  addition  the  hair  ^^**^ 
is  usually  extraordinarily  coarse  and  wiry,  and  on  more  than  one(3o»>>"  ^ 
occasion  I  have  known  the  teeth  of  the  clipper  to  be  broken 
whilst  the  hair  was  being  cut. 

As  already  remarked,  the  cranial  circumference  in  these 
cases  varies  very  much,  and  the  diagnostic  feature  is  one  of 
shape  rather  than  of  size.  There  have  been  several  cases  re- 
corded in  which  the  greatest  circumference  w^as  15  inches  or 
under  ;  on  the  other  hand,  I  know  several  typical  microcephalics 
with  a  cranial  circumference  of  19  inches  and  more,  and  one  whose 

*  T.  W.  McDowall,  "  Abnormal  Development  of  the  Scalp,"  Journal 
of  Mental  Science,  January,  1893. 

t  Dr.  McDowall  was  good  enough  to  place  a  portion  of  the  scalp  of  one 
of  these  patients,  who  died  under  his  care,  at  my  disposal  for  examination. 
I  found  a  considerable  thickening  of  all  layers,  the  average  thickness 
down  to  the  roots  of  the  hair  follicles  being  from  4  to  5  millimetres,  and 
this  after  hardening  in  spirit. 

12 


178  Mental  Deficiency 


skull  measures  as  much  as  21  inches.  It  is  to  be  remembered 
that  the  actual  brain  capacity  is  less  than  a  mere  circumferential 
nleasurement  would  suggest,  by  reason  of  the  deficiency  being 
chiefly  in  the  upper  parts  of  the  skull. 

The  second  characteristic,  that  of  diminished  stature,  is  not  so 
constant  ;  nevertheless,  as  a  class,  microcephalics  are  the  smallest 
of  the  varieties  of  amentia,  and  many  of  them  may  be  called 
dwarfs.  Few  of  them  grow  to  more  than  5  feet,  although  "  Joe  " 
(described  by  Dr.  Ireland)  reached  5  feet  9  inches  in  his  boots. 
But  this  is  decidedly  exceptional. 

In  other  respects  microcephalics  present  the  anomalies  common 
to  aments  in  general,  and  which  have  already  been  described. 
They  rarely  hve  to  an  advanced  age  (in  this  respect  also  I  think 
"  Joe  "  is  unique,  since  he  was  sixty  years  old  at  his  death),  and 
th^majority  die  of  tuberculosis. 

Mentarana  Nervous  ^bndttion, — ^The  intellecttial  capacity  of 
these  persons  varies  within  very  considerable  limits,  and  we  thus 
have  microcephalic  aments  of  each  of  the  three  degrees  of 
deficiency.  A  considerable  number  are  idiots,  unable  to  do  any- 
thing~^for  themselves,  unable  to  understand  more  than  a  few 
words,  and  incapable  of  speech.  Others,  and  the  majority, 
belong  to  the  imbecile  class,  and  are  capable  of„uiiderstanding 
most  of  what  is  said  to  them,  can  say  a  few  words,  and  can 
perform  simple  tasks.  A  few  are  merely  feeble-minded.  The 
case  of  "  Joe  "  is  probably  the  best  example  of  the  mildest 
degree  of  defect,  for  Dr.  Ireland  says  that  until  after  forty  years 
of  age  he  was  apparently  able  to  earn  sufficient  wages  to  main- 
tain himself.  I  know  several  typical  microcephalics  amongst 
mentally  defective  children  attending  special  schools  who  can 
read,  write,  do  simple  sums,  and  who  probably  possess  sufficient 
intelligence  to  earn  their  living  under  supervision  ;  and  one  woman 
of  this  type,  with  a  cranial  circumference  just  under  17  inches, 
is  one  of  the  most  industrious  inmates  of  a  county  asylum. 

The  mental  features  common  to  most  microcephalics  are 
tb^^^-absenre  q\  anv  sensory  defect,  a  general  viyacitya_j;estless- 
ness  and  muscular  activity,  a  considerable  capacity  for  imita- 
tion, and,  usually,  an  inabilityTonr'sustained  ef^rt.  In  their 
perceptive  faculties  these  persons  often  compare  favourably  with 
aments  of  considerably  higher  general  intelligence,  and  many 


The  Clinical  Varieties   of  Primary  Amentia    179 

of  them  not  only  have  remarkably  good  hearing  and  sight,  but 
extremely  quick  powers  of  observation.  The  restlessness  is 
sometimes  expressed  by  the  performance  of  peculiar  actions 
which  have  caused  them  to  be  likened  to  various  animals.  Thus, 
Lombroso  describes  a  **  bird  man,"  a  "  rabbit  man,"  and  a 
**  goose  man."  Their  power  of  mimicry  is  often  very  marked, 
and  this,  combined  with  their  general  alertness,  causes  them  to 
be  amongst  the  drollest  inmates  of  the  imbecile  w^ard.  There 
was  a  chattering,  restless  ament  of  this  type  at  Darenth  a  few 
years  ago,  who  was  very  pat  in  making  remarks  upon  anything 
coming  under  his  observation,  and  who  was  a  source  of  endless 
amusement  to  the  attendants  by  his  witticisms  concerning  one 
of  them  in  particular.  Another  boy,  aged  eleven  years,  with  a 
cranial  circumference  of  15 1  inches,  was  most  adept  in  mimicking 
the  various  performers  in  the  band. 

In  disposition  the  majority  are  affectionate  and  well-behaved. 
Many  of  them,  before  training,  it  is  true,  are  apt  to  be  quarrel- 
some and  difficult  to  manage,  but  they  usually  soon  lose  these 
propensities  and  become  quite  amenable  to  the  discipline  of  an 
institution. 

The  majority  of  microcephalics  of  the  idiot  degree  suffer 
from  a  condition  of  general  helplessness,  which  causes  them  to  be 
unable  to  do  anything  for  themselves,  and  many  of  the  imbecile .__ . 
grade  even  experience  considerable  difficulty  and  unsteadine§aJfl— ;» 
walking.  THTs  does  not  appear  to  be  due  to  actual  paralysis 
Talthough  I  have  seen  a  few  cases  \yith  t3rpical  spastic  paralysis 
and  increased  tendon  reflexes),  but  to  an  imperfect  development 
of  the  tracts  of  the  spinal  cord.  About  half  of  them  are  subject 
to  epjleptic  fits. 

In  conclusion  we  may  briefly  cite  the  chief  instances  of  this 
interesting  condition  which  have  been  recorded.* 

Dr.  Wilbur  described  (1857)  an  idiot  aged  twelve  years,  in  the 
New  York  State  Asylum,  whose  cranial  circumference  was  only 
13J  inches.  He  was  passionate,  uncleanly  in  his  habits,  could 
distinguish  a  variety  of  forms  and  colours,  knew  the  names  of 
all  objects  in  the  schoolroom  and  about  the  house,  and  recognized 
a  great  number  of  pictures  of  objects.  He  made  but  httle  pro- 
gress in  speaking,  and  after  being  in  the  asylum  five  years, 

*  For  these  particulars  I  am  largely  indebted  to  Dr.  Ireland's  work. 

12 — 2 


i8o  Mental  Deficiency 

though  improved  in  many  respects,  he  was  found  incapable  of 
further  progress,  and  was  dismissed. 

Antonia  Grandoni  was  described  by  Professor  Filippo  Cardona 
of  Milan  (1870).*  She  was  a  typical  microcephalic,  with  a  cranial 
circumference  of  15  inches  ;  her  height  was  49J  inches ;  and  she 
died  at  the  age  of  forty-one  years.  She  had  no  sensory  deficiency ; 
in  fact,  her  hearing  was  very  quick  and  her  observation  very  keen. 
She  understood  what  was  said  to  her,  and  was  able  to  converse. 
She  had  a  good  memory  for  persons  and  events,  was  of  a  sociable 
and  decidedly  amorous  and  erotic  disposition,  and  much  addicted 
to  dancing.  Although  decidedly  defective,  she  had  sufficient 
intelHgence  to  do  simple  domestic  duties  and  to  run  errands ;  in 
fact,  considering  the  extremely  small  size  of  her  brain,  her 
intelligence  was  altogether  remarkable. 

Helene  Becker  died  of  phthisis  at  the  age  of  eight  years,  and  a 
very  careful  and  complete  examination  was  made,  and  report 
published,  by  Dr.  Bischoff  of  Munich  {iSy^).-\  This  girl  was  a 
low  grade  idiot  ;  she  knew  her  own  name,  but  was  practically 
incapable  of  understanding  anything  beyond,  although  she  knew 
when  people  were  angry  with  her.  Her  speech  was  limited  to 
one  word.  She  was  very  restless,  always  moving  her  hands  and 
arms  and  the  upper  part  of  her  body.  The  brain  weighed 
219  grammes.     Another  child  in  the  family  was  microcephalic. 

The  "  bird  man,''  a  microcephalic  with  a  cranial  circumference 
of  15  inches,  was  described  by  Professor  Cesare  Lombroso  (1873).  J 
He  was  so  named  from  a  habit  of  chirping  like  a  bird,  hiding  his 
head  under  his  armpit,  leaping  on  one  leg,  and  stretching  out 
his  arms  like  wings.  He  was  said  to  be  wanting  in  touch,  taste, 
and  smell,  was  dirty  in  his  habits,  and  given  to  coprophagy. 
Professor  Lombroso  also  recorded  two  other  microcephalics  under 
the  designation  of  the  "  rabbit  man  "  and  the  **  goose  man,"  also 
the  three  brothers,  Nicolb,  Serafino,  and  Giovanni  Cerretti.  These 
were  aged  twenty-one  years,  thirteen  years,  and  ten  years,  and  had 
a  skull  circumference  of  17J,  16J,  and  ibj  inches  respectively. 

The  ''Aztecs  "  were  a  pair  of  microcephalic  aments,  boy  and  girl, 
of  American-Indian  origin,  who  were  exhibited  all  over  Europe 

*  D'  Una  Micvocefala,  Milano,  1870. 

■(•  Anatomische  Beschreibung  eines  mikrocephalen,  8  Jdhrtgen  Madchens. 

X  Rivista  Clinica  di  Bologna,  July  and  November,  1873. 


The  Clinical  Varieties  of  Primary  Amentia    i8i 

and  America  for  forty  years,  and  who  have  been  described  at 
various  periods  by  different  writers,  including  Professor  Owen. 
They  were  seen  by  Dr.  Dalton  when  aged  seven  and  five  years 
respectively,  and  were  described  as  being  only  able  to  repeat 
a  few  isolated  words,  but  very  excitable,  vivacious,  in  almost 
constant  motion,  and  full  of  curiosity.  Their  habits  as  regards 
feeding  and  taking  care  of  themselves  were  those  of  children 
two  or  three  years  old.  They  were  publicly  married  in  London 
in  1867,  but  had  no  offspring. 

Freddy,  who  was  under  the  observation  of  Dr.  Shuttleworth 
for  twenty  years  at  the  Royal  Albert  Asylum,  died  at  the  age  of 
twenty-nine  years,  of  ,phthisis.  At  the  time  of  his  death  his 
height  was  4  feet  8  inches,  the  cranial  circumference  was 
15  inches,  and  the  weight  of  the  fresh  brain  was  12  J  ounces.  The 
cranial  circumference  at  eight  years  was  14 J  inches,  and  at  twelve 
years  14J  inches.  Dr.  Shuttleworth  describes  him  as  manifesting 
good  powers  of  observation,  but  only  able  to  express  himself  in 
a  few  monosyllabic  words.  He  had  considerable  will-power,  and 
though  it  was  found  impossible  to  train  him  to  much  that  was 
useful,  he  was  in  no  sense  a  low-grade  idiot.  A  very  complete 
examination  of  this  case  was  made  and  recorded  by  Professor 
J.  D.  Cunningham  and  Dr.  T.  Telford-Smith  (1895).* 

Joe,  who  was  examined  by  Dr.  Ireland  in  the  Lancaster 
Workhouse  at  the  age  of  forty-five  years,  had  a  cranial  circum- 
ference of  17  inches,  and  attained  the  unusual  height  of 
5  feet  9  inches  (in  boots).  Until  eighteen  months  previously 
he  had  earned  enough  wages  to  keep  himself,  and  he  died  at  the 
age  of  sixty  years,  of  phthisi^.  This  case  also  was  fully  described 
by  Cunningham  and  Telford- Smith. 


MONGOLIAN  AMENTIA. 

The  Mongolian  or  Kalmuc  variety  of  amentia  was  first  so  named 
by  Dr.  J.  Langdon  Down,  from  the  resemblance  of  these  persons 
in  certain  particulars  to  members  of  the  Mongolian  race.     Their 

*  Transactions  Royal  Dublin  Society,  vol.  v.,  Series  2,  Part  VIII. 
An  excellent  recent  account  of  microcephaly  is  that  by  Dr.  Giovanni 
Mingazzini  [Monatsschrift  fur  Psychiat.  und  Neurologie,  Band  vii.,  Heft  6, 
June,  1900).     This  gives  most  of  the  literature  to  date. 


1 82  Mental  Deficiency- 

peculiar  characteristics  give  rise  to  a  physiognomy  and  cHnical 
appearance  which  is  exceedingly  distinctive  and  unmistak- 
able, but  it  must  be  admitted  that  not  a  few  aments  are  met 
with  who  present  only  some  of  the  features  of  this  class,  and 
who  are  thus  intermediate  between  the  Mongolian  and  the  simple 
variety  of  amentia.     Such  are  often  called  "  semi- Mongols." 

The  number  of  Mongols  is  not  large.  If  only  those  with  well- 
marked  characteristics  be  included,  they  probably  do  not  form 
^more  than  about  4  or  5  per  cent,  of  all  aments.  One  often  hears 
it  said  that  they  are  on  the  increase,  but  I  know  of  no  data  in 
support  of  this  statement,  and  impressions  regarding  such 
matters  are  notoriously  misleading.  Still,  it  is  by  no  means 
improbable.  Many  of  the  physical  features  of  this  class  are 
noticeable  at,  or  shortly  after,  birth,  and  this  fact,  together  with 
their  retardation  of  development,  causes  them  to  be  not  infre- 
quently seen  in  the  consulting-room  and  the  out-patient  depart- 
ment of  hospitals  devoted  to  children.  They  bear  a  superficial 
resemblance  to,  and  are  often  confounded  with,  cretins  ;  in  fact, 
this  type  of  amentia  used  fornierly  to  be  called  "  cretinoid  " 
idiocy. 

Causation. — Dr.  G.  A.  Sutherland,*  in  one  of  the  best  accounts 
we  have  of  Mongolism  as  seen  in  the  early  years  of  life,  remarks 
that  these  children  "  resemble  each  other  so  closely  that  they 
appear  to  be  members  of  the  same  family,"  and  he  very  truly 
argues  from  this  that  the  cause  is  more  likely  to  be  particular 
than  general,  such  as  those  concerned  in  the  production  of 
the  majority  of  aments.  "  General  causes,"  he  says,  "  such  as 
parental  alcoholism,  nervous  disease,  or  insanity  in  the  family, 
etc.,  are  not  likely  to  produce  such  an  exact  type  of  disease  as 
exists  in  Mongolism.  It  seems  probable  that  one  and  the  same 
cause  is  at  work  in  all  cases."  Sutherland  found  that,  out  of  his 
total  of  twenty-five  cases,  syphilis  was  definitely  present  in  eleven 
patients,  and  from  the  •  symptoms  and  history  it  was  strongly 
suspected  ia  three  others.  He  therefore  suggests  that,  whilst 
further  investigation  is  required  to  ascertain  the  exact  etiological 
factor,  the  condition  may  turn  out  to  be  a^parasyphilitic  one.  \^ 

It  is  undoubtedly  true  that  the  curious  "assemblage  of  physical 

*  G.  A.  Sutherland,  •"  Mongolian  Imbecility  in  Infants,"  based  on  a 
study  of  twenty-five  cases.  Practitioner,  December,  1899. 


I 


I 


The  Clinical  Varieties  of  Primary  Amentia    183 

signs  which  are  present  in  typical  Mongohsm  do  suggest  a  certain 
uniformity  of  causation  in  these  cases.  But  it  is  necessary  to 
remember  that  Mongohsm  consists  in  a  particular  combination 
of  anomalies  rather  thah'irTanomalies  which  ar£_distinctive  In 
tHemseTves,  and  there  are  many  ordinary  aments  who  possess 
one  or  more  of  the  features  which  go  to  make  up  the  tout  ensemble 
of  the  Mongol ;  in  fact,  I  do  not  know  of  any  single  feature  of 
these  persons  (with  the  possible  exception  of  the  tongue)  which 
may  not  be  seen  in  other  aments.  It  is,  therefore,  the  comhina' 
Hon  only  which  is  distinctive.  Granting,  however,  that  this 
is  probably  due  to  a  uniform  cause,  it  by  no  means  follows 
that  this  is  some  single  and  particular  etiological  factor.  With 
regard  to  the  question  of  syphihs,  the  evidence  produced  by 
Dr.  Sutherland  is  undoubtedly  very  strong  ;  but,  as  equally 
strong  evidence  to  the  contrary,  it  may  be  stated  that,  in  over 
twenty  cases  of  this  variety  in  which  I  investigated  the  family 
history,  I  was  unable  to  discover  any  preponderance  of  syphilis, 
and  in  some  of  the  cases  I  have  no  hesitation  in  saying  positively 
that  syphihs  was  not  to  be  thought  of.  In  nearly  all  my  cases 
there^ffias^ajieurppathic  family  history,  and  frequently  a  strong 
tiibercular^taint  ;  but  o\-er  and  beyond  this,  what  I  did  fre- 
quently find  (and  what  I  think  may  possibly  be  the  factor 
common  to  this  type)  was  a  history  pointing  to  a  condition  of  ^j 
uterine  exhaustion  or  ill-health  of  the  mother  during  gestationu^ 
Many  of  the  patients  were  the  later  born  of  a  large  family,  olteii 
numbering  as  many  as  ten  or  twelve,  and  where  this  was  not  the 
case  there  was  usually  a  statejol^evere-physical -prostration  of 
the  mother  during  the  gestation  period.*  It  is  possible  that 
many  conditions,  syphilis  included,  may  bring  this  about,  and 
I  have  on  several  occasions  seen  children  produced  by  weakly 

*  Dr.  Bodil  Hjorth,  of  Copenhagen,  in  a  paper  recently  published  on  the 
"  Etiology  of  Mongolism,"  gives  particulars  regarding  the  antecedents  of 
twenty-one  cases.  "  The  observed  conditions  assumed  as  possible  causes 
are  phthisis  in  the  parents  or  grandparents,  neuropathic  heredity,  and 
alcoholism.  None  of  these  occur  so  often  as  to  show  a  preponderating 
influence.  There  is  no  record  of  syphilis  in  any  of  the  cases.  Twins 
presenting  the  specific  characters  are  noted,  these  children  being  the 
eighth  and  ninth  of  a  familj^  of  ten.  Out  of  the  twenty-one  cases,  twelve 
were  the  last  children  in  the  family"  (Journal  of  Mental  Science,  January, 
1907). 


184  Mental  Deficiency 

mothers,  at  the  end  of  the  child-bearing  period,  who  had  quite  a 
MongoHan  type  of  physiognomy,  but  who  were  mentally  normal. 

I  am  disposed  to  think,  therefore,  that  Mongolian  amentia  is  the 
result  of  the  two  factors,  morbid  heredity  and  uterine  exhaustion, 
and  that  with  a  pronounced  degree  of  the  latter  the  hereditary 
defects  may  be  only  slight.  In  one  of  my  cases  there  was  no 
neuropathic  heredity,  but  the  mother  had  suffered  from  severe 
albuminuria  and  anaemia  whilst  carrying  the  child. 

Pathology. — The  brain  of  the  Mongol  is  usually  smaller  and 
less  complexly  convoluted  than  that  of  the  normal  person.  In 
addition,  jthere  is  a  diminution  in  the  size  of  the  pons,  medulla, 
and  cerebellum.  This  is  not  a  noticeable  peculiarity  of  ordinary 
aments,  and  it  seems  to  be  a  constant  characteristic  of  this  class. 
Dr.  A.  W.  Wilmarth,*  as  a  result  of  the  examination  of  five 
Mongols,  found  that  the  brains  were  of  good  size  for  imbecile 
brains,  but  that  the  pons  and  medulla  were  very  small,-  being 
"only  about  half  the  normal  weight.  He  suggests  that  the  low 
nutrition  of  these  patients  (and  possibly  other  anatomical  pecu- 
liarities) may  be  due  to  the  imperfect  development  or  absence 
of  certain  cell  groups  in  this  region. 

I  have  had  the  opportunity  of  examining  the  central  nervous 
system  of  a  male  Mongolian  who  died  aged  fourteen  days.  In 
this  the  weight  of  the  complete  encephalon  was  340  grammes, 
which  may  be  considered  as  normal.  The  weight  of  pons, 
medulla,  and  cerebellum  was  19  grammes,  the  relationship 
between  these  structures  and  the  cerebrum  being  thus  i  to  16 "8. 
According  to  Huschke,  the  normal  relationship  between  these 
and  the  cerebrum  is  as  7  to  93  (roughly,  one-thirteenth)  at  birth. 
The  relative  and  absolute  weight  of  the  cerebellum  undergoes  a 
considerable  increase  with,  age,  however,  and  in  the  adult  the 
proportion  to  the  cerebrum  is  as  13  to  87  (roughly,  one-seventh). 
it  is  thus  seen  that  in  this  case  there  is  a  definite  diminution 
of  these  basal  structures.  No  other  naked-eye  changes  were 
observed.  Microscopical  examination  showed  an  immature  con- 
dition of  the  cells  and  tracts  of  all  portions  of  the  encephalon 
and  spinal  cord  ;  but  the  degree  of  development  did  not  appear 

♦  A.  W.  Wilmarth,  "  Report  on  the  Examination  of  One  Hundred 
Brains  of  Feeble-Minded  Children,"  Alienist  and  Neurologist,  October, 
1890. 


Plate  XII. 


> 


To  face  page  184.] 


OF  rn^   ^  \ 

''■■u.RBlTY    * 

OF 


e 


The  Clinical  Varieties  of  Primary  Amentia    185 

to  be  behind  that  of  a  normal  nervous  system  of  similar 
age.  The  brain  cells  of  the  normal  child  at  birth  are  in  a  very 
embryonic  condition,  however,  and  it  is  hardly  to  be  expected 
that  any  microscopical  differences  would  be  discoverable  at  this 
early  age. 

It  is  very  probable  that  the  imperfect  development  of  the 
basal  parts  of  the  encephalon  results  in  a  deficient  expansion  of 
the  base  of  the  skull,  and  Sutherland  plausibly  suggests  that  this 
niay^e  alactornn  causing  the  characteristic  physiognomy  of 
these  persons. 

It  may  be  stated  that,  beyond  the  presence  of  congenital 
malformations  common  to  all  aments,  dissections  have  hitherto 
^failed  to  reveal  any  abnormality  of  glandular  or  other  bodily 
structures  whrdi  would  account  for  the  peculiar  characteristics 
di-this  class.  The  amentia  is  in  all  probability  idiopathic 
and  due  to  hereditary,  defects,  but  these  special  physical 
"  cnaractenstics  niay  be  brought  about  by  morbid  influences 
or  malnutrition  acting  during  the  period  of  intra-uterine 
growth. 

Description. — Physical  Condition. — ^The  three  anomalies  most 
constantly  present  in  Mongolism,  and  whose  combination  may  be 
said  to  be  characteristis^pf  this  condition,  are  of  the  skull,  the  pal- 
pebral  fissures,  and  the  tongue.  These  are  often  so  pronounced' 
as  tojifuLden-a  diagnosis  possible  at,  or  very  shortly  after,  birth. 
In  exceptional  cases,  however,  only  two  may  exist.  In  addition, 
there  are  man);^*!^  peculiarities  of  frequent  occurrence  ;  but 
these  are  less  ^^^^^ve  of  Mongols,  many  of  them  being  by 
nonieans_^I^Lr^^^^Piinary  aments.  Severariihis^rations  of 
this  type  of  amentia  are  shown  in  Plates  XII.,  XIII.,  ^c^ 
and  XIV.  '^^C^ 

The  skuU  is  small,  rounded,  and  diminished  in  its  antero-    jq*) 
posterior  measurement  (brachy cephalic),  the  face  and  occiput     \j^ 
being  considerably  flattened!     BumiSI^is  no  marked  recession 
of  the  frontal  and  supra-occipital  regions,   so  that,   although 
Mongols  are  of  the  small-headed  type  of  aments,  the  cranial  con- 
formation is  markedly  different  to  the  microcephales  proper.    The         ^r 
palpebral  fissures  are  narrow  and  oblique,  sloping  downwards  an4  *. 
imvards.     It  was  this  peculiarity  which  caused  Langdon  Down     ^ 
to  apply  the  name  "  Mongol  "  to  the  type  ;  but  although  generally 


1 86  Mental  Deficiency 

present,  it  is  not  invariably  so.  Dr.  C.  H.  Fennell,*  in  a  series 
of  twenty-one  cases,  found  it  absent  in  three,  whilst  in  one  the 
direction  was  reversed.  Moreover,  it  occurs  in  the  mentally 
sound,  and  I  know  several  remarkably  inteUigent  persons  pos- 
sessing this  peculiarity. 

An  exceedingly  characteristic  feature  is  the  tongue,  which 
is  unusually  large,  marked  by  hypertrophied  circumvallate 
papillae,  and  scored  by  a  series  of  irrp^^r  trangA/prc^-^ssures^ 
Fennell  regards  this  condition  as  pathognomonic,  and  says  : 
"  In  the  examination  of  the  tongue  in  over  200  idiots  of  all 
other  types,  I  met  with  none  which  at  all  recalled  it."  But 
a  few  Mongols  of  mature  age  do  not  present  this  peculiarity. 
Some  very  interesting  details  with  regard  to  the  tongue  have 
been  recorded  by  Dr.  John  Thomson, f  of  Edinburgh.  He  finds 
that,  although  the  organ  may  be  noticeably  large  at  birth,  the 
other  characteristics  of  fissuring,  swollen  papillae  and  sodden 
rawness,  do  not  develop  until  considerably  later.  He  says  the 
enlargement  of  the  papillae  most  commonly  begins  between  the 
third  and  ninth  months,  whilst  the  fissuring  generally  begins  to 
appear  in  the  course  of  the  third  or  fourth  year.  It  may  be 
present  in  a  slight  form,  however,  during  the  second,  and  it  may 
not  be  noticeable  till  as  late  as  the  sixth  year.  Dr.  Thomson 
suggests  that  these  changes  may  be  partly  due  to  an  abnormal 
vulnerability  of  the  mucous  membrane,  but  that  what  chiefly 
determines  the  swelling  and  cracking  is  the  habit  of  sucking  the 
tongue  which  is~cbmmonly  present  in  these  children.  I  am  of 
opinion  that  this  is  an  exceedingly  probable  explanation,  for  it  is 
an  undoubted  fact  that  a  very  marked  feature  of  Mongolism  is  the 
tendency  to  chronic  inflammatory  conditions  of  skin  and  mucous 
membranes  ;  whilst  Thomson  has  shown  that  the  exciting  factor — 
toDgiie'Sucki.ng — occurs  in  at  least  8q_per^ent.  of  thesej)atients. 

The  ears  are  usually  small  and  rounded,  the  nose  short  and 
squat,  with  triangular  nostrils  which  often  look  forwards  rather 
than  downwards.  Epicanthus  is  often  seen,  and  strabismus  and 
nystagmus  are  frequent  in  the  first  few  months  of  Uf e,  but  tend  to 

*  C.  H.  Fennell,  "  Mongolian  Imbecility,"  Journal  of  Mental  Science, 
January,  1904.  An  excellent  account  of  Mongolism  as  seen  in  institutions, 
based  upon  twenty-one  cases. 

f  John  Thomson,  "  Notes  on  the  Peculiarities  of  the  Tongue  in  Mon- 
golism," British  Medical  Journal,  May  4,  1907. 


-   Plate  Xtll. 


.0)      "S 


Is! 


be  o 


a;  en 


To  /ace  page  186.] 


/  ^    THE 

OF 


The  Clinical  Varieties  of  Primary  Amentia    187 

disappear  as  the  child  grows.  Speckled  irides  are  very  cpminon, 
a  conditioxL-to  which- my  attention,  was  first  drawn  by  Dr.  R. 
Langdon  Down.  The  same  observer  also  considers  that  hyper- 
metropic astigmatism  is  unusually  prevalent.  The  hair  is  generally 
very  scanty  and  wiry.  There  is  frequently  seen  a  bright  red 
fluslT'opon  the  |cheek  of  these  patients,  very  much  like  that 
occurring  in  myxcedema.  The  palate  is  often  high  and  narrow, 
the  mouth  open,  and  the  tongue  partly  protruding.  Adenoids 
are  exceedingly  frequent. 

The  hands  and  feet  are  commonly  broad,  flabby,  and  ex- 
ceedingly clumsy-looking  ;*iTrfact7they  may  often  be  said  to  be 
spade-Hke: — DrTTelf or d- Smith  described  a  curious  incurving  of 
the  little  fingers  as  very  characteristic  of  Mongolism,  but  in  my 
experience  it  is  no  more  common  in  this  type  than  in  aments  in 
general.  What  I  have  frequently  found  is  that  both  the  little 
fingers  and  thumbs  are  much  shorter  th^an  normal,  and  that  whereas 
in  the  ordinary  person  or  ordinary  ament  the  tip  of  the  little 
finger  usually  ends  opposite  the  last  joint  of  the  ring-finger,  in 
Mongols  it  is  very  common  to  find  it  extend  no  farther  than  the 
middle  of  the  second  phalanx.  In  the  early  years  of  life  there 
is  usually-air^xceedingly  lax  condition  of  the  joint  ligaments, 
and  this  gives  rise  to  a  greatly  increased  mobility.  Very  often 
the  fingers  and  knees  can  be  hyperextended  to  a  considerable 
degree.  Knock-knee  and  fiat-foot  are  common.  The  skin  is 
rough  and  dry,  and  often  covered  with  fine  hairs.  The  sub- 
cutaneous tissues  frequently  have  a  curious  boggy  feehng,  like 
that  present  in  myxcedema,  but  there  is  no  pitting  on  pressure. 
The  abdomen  is  usually  large  and  tumid,  particularly  in  infancy, 
and  umbilical  hernia  is  occasionally  seen. 

In  many  of  these  persons  the  circulation  is  very  defective,  and 
blueness  and  coldness  of  the  extremities,  sores  and  chilblains, 
are  exceedingly  prevalent.  This  is  probably  due  to  congenital 
cardiac  anomalies,  such  as  imperfect  closure  of  the  foramen  ovale, 
pulmonary  stenosis,  etc.  ;  but  in  some  instances  it  may  be 
the  result  of  intra-uterine  endocarditis.  Dr.  A.  E.  Garrod* 
described  five  cases  of  Mongolism  in  which  congenital  cardiac 
Jesions  were  foun^' and  ofle-hitn  01  tne^^j^ases— exnmmcS^-by- 
Dr.  Sutherlahd  pietieiiltld  WTrll-iniUkecTs^olic  basal  murmurs 

*  Archibald  E.  Garrod,  British  Medical  Journal,  October  22,  1898. 


^ 


1 88  Mental  Deficiency 

which  were  evidently  congenital.  One  very  marked  peculiarity 
of  these  persons  \is  their  tendency  to  chronic  inflammatory 
lesions  of  the  respiwo^jfy  and  alimentary  tracts.  Xasal  catarrh, 
bronchitis,  and  diarrhoea  are  exceedingly  common,  and  the 
majority  are  constant  sufferers  from  blepharitis,  rhinitis,  and 
cracked  hps. 

Such  are  the  chief  physical  peculiarities  of  this  interesting 
variety  of  amentia.  It  is  rarely  that  they  are  all  present  in  any 
one  person,  and  there  is  probably  no  one  of  them  which  is  really 
pathognomonic  of  this  condition,  except  perhaps  the  tongue. 
This  latter,  with  the  peculiar  conformation  of  the  skull  and 
palpebral  fissures,  the  cheek  flush,  and  the  general  tendency  to 
m'ucousTatarrh,  Seem  ±o  me  to  constitute  the  essential  symptom - 
complex.  As  a  rule,  these  peculiarities  persist  throughout  life  ; 
but  I  have  seen  a  few  cases  in  which  advance  of  time  seemed  to 
bring  about  a  marked  amelioration,  and  caused  them  to  become 
much  less  evident.  This,  I  think,  is  more  common  in  the 
originally  milder  cases  ;  but  a  short  time  ago  Dr.  Caldecott,  of 
Earlswood  Asylum,  showed  me  an  imbecile  whom  the  casual 
observer  would  hardly  have  recognized  as  a  Mongol,  but  who  in 
former  years  had  possessed  very  well-marked  characteristics. 

As  a  rule,  Mongols  die  early,  the  chief  cause  of  death  being 
j^Jllllisis.  They  are  rarely  met  with  above  the  age  of  thirty  years, 
although  at  the  present  time  there  are  two  at  Normansfield 
between  thirty  and  forty  ;  and  Dr.  R.  Langdon  Down  tells  me 
that  he  had  a  female  Mongolian  under  his  care  for  many  years 
who  reached  the  advanced  age  of  fifty-seven  years. 

Mental  and  Nervous  Condition. — ^The  mental  characteristics  of 
this  class  are  not  nearly  so  distinctive  as  are  the  physical ;  never- 
theless, fhefe'are  several  peculiarities  common  to  them.  From 
the  beginning,  the  Mongolian  infant  is  placid,  ^ood- tempered, 
iand'^tcadil y^muieS!  There  is  at  first  no  apparent  mental  hebe- 
tude ;  on  the  contrary,  he  often  looks  bright  and  intelHgent,  has 
plenty  of  curiosity,  is  attracted  by  everything  around  him,  and 
is  very  imitative.  But  one  of  the  most  common  of  the  early 
^ji|pas._iDf--ameHtk-is  -seeaJLQ^he  tardy  evolution  of  the  power  of 
-Sittmg  u^,  wal^ng».Rnd  talking.  MoreoverThe  is  full  of  grimaces 
and  facial  contortions,  which  are  accompanied  by  wrinkling  of 
the  skin,  and  are  foreign  to  the  normal  child.     As  he  grows  up 


Plate  XIV. 

PRIMARY   AMENTIA   (MONGOLIAN   VARIETY). 


Fig.  37. — A  female  Mongolian.     Age,  3  months. 
(Frotn  a  photograph  lent  by  Dr.  J.  ■  Thomson.) 


Fig.  38. — A  male  Mongolian.  Age,  14  months.  With 
talipes  varus  and  cubitus  varus.  Died  2  months 
later  of  general  tuberculosis. 

{From  a  photograph  lent  by  Dr.  J.  Thomson) 


Tc  face  page 


The  Clinical  Varieties  of  Primary  Amentia    189 

the  want  of  intellect  becomes  more  and  more  apparent.  But  he 
still  retains  his  happy  disposition  ;  he  is  very  affectionate,  readily 
pleased,  and  usually  a  great  favourite  with  all  around  him.  He 
often  has  a  very  considerable  power  of  mimicry,  as  well  as  a 
^rhafEable  sense  of  rhythm  andlove'of  rnusTc7  an'd"rMn^ 
children  are  adepts  at  drill  and  dancing. 

""  The  degree  of  intellectual  deficiency  varies  very  considerably, 
and  on  the  whole  I  am  inclined  to  think  that  there  is  a  direct 
relation  between  this  and  the  intensity  of  the  bodily  signs. 
Many  of  them  are  merely  feeble-minded,  a  few  are  pronounced 
idiots,  but  the  majority  belong  to  the  medium  grade  of  defect. 
The  milder  members  generally  learn  to  read,  wTite,  and  perforrn 
simple  duties  with  a  fair  amount  of  inteUigence,  but  their  power 
of  summing  is  decidedly  poor.  Dr.  Shuttleworth  says  that  some 
of  thp.5;e^  .^^^^^  p^ppropn'ate  education,  even  pass  muster  with  their_ 
and  sisters.     The  imbeciles,  on  the  other  hand,  rarely 


make  much  neadway,  and,  although  very  imitative,  it  is  not  often 
that  in  them  this  faculty  can  be  turned  to  any  practical  purpose. 
In  the  performance  of  useful  work  they  are  often  surpassed  by 
ordinary  imbeciles  of  far  more  vacant  and  less  prepossessing 
appearance.  Even  in  the  milder  cases  the  clumsy  and  ill-formed 
condition  of  the  hands  usually  precludes  any  kind  of  work 
requiring  dexterity,  and  most  of  these  persons  do  best  in  the 
garden  or  on  the  farm. 

Cerebral  complications  are  not  common  in  this  class,  and  actual 
paralysis  and  epilepsy  are  rare  in  comparison  with  other  aments. 

It  will  be  seen  that  Mongolian  aments  have  certain  points  in 
common  with  sporadic  cretins,  and  in  the  early  stages  a  con- 
siderable number  are  treated  with  thyroid  gland,  and  hopes  of 
amelioration  held  out  to  the  parents,  as  a  result  of  a  mistaken 
diagnosis.  The  chief  points  of  resemblance  are  the  general  back- 
wardness of  bodily  development,  the  stumpy  and  spade-like  hands 
and  feet,  the  squat  nose,  and  the  bogginess  of  the  subcutaneous 
tissues.  Careful  examination,  however,  will  reveal  far  more 
points  of  difference.  In  the  Mongols  the  head  is  small  and 
rounded,  instead  of  large  ;  the  tongue,  although  somewhat  like 
4hat  of  the  cretin  in  being  large  and  protruding,  is  marked  by 
jiypertrophied  pagljgT'aiidr  later  ISy"  numerous  fisbuiesr  The 
slant  of  the  eyes,  ithe  lax  joints,  and  tne  chronic  catarrh  of  the 


190  Mental  Deficiency 

Mongol  are  very  distinctive ;  whilst  his  active,  bright,  and 
vivaciousjnanner  is  totally  unlike  the  dull,  expressionlf^ss  inertia 
of  the  cretin.  Finally,  the  rate  of  bodily  growth  is  entirely  '^ 
different  in  the  two  conditions.  I  have  known  thyroidgland^, 
also  thymus  and  pituitary  extracts,  given  to  Mongols  persistently 
for  years,  but  never  with  any  appreciable  amelioration  of  the 
physical  or  mental  defects  ;  whereas,  as  is  well  known,  the  effect 
of  thyroid  upon  the  cretin  is  remarkable. 


THE  COMPLICATIONS  OF  PRIMARY  AMENTIA. 

We  have  described  three  types — ^namely,  Simple,  Microcephalic^ 
and  Mongolian — -asthaxhifif-^linical  varieties  .of  primai-y  j:^.pi^r)tia-  ...^ 
Any  of  these  three,  however,  may  be  complicated  by  certain 
severe  developmental  anomalies  or  special  pathological  condi- 
tions which  produce  more  or  less  distinctive  clinical  features,  and 
these  we  shall  now  allude  to.     They  are,  in  order  of  frequency  : 

Hydrocephalus. 

Porencephalus. 

Sclerosis.  j 

Deaf-mutism, 
It  is  to  be  remarked  that,  in  the' cases  we  are  now  considering, 
these  conditions  merely  accompany  and  complicate  a  mental 
deficiency  which  is  primary  ;  nevertheless  similar  lesions  may, 
in  a  small  number  of  instances,  actually,  produce  amentia.  Such 
cases  will  be  dealt  with  in  a  subsequent  chapter. 

Epileptic  and  Other  Convulsions. — Convulsions  in  some  form  or 
other,  but  chiefly  epileptic,  are  the  most  common  complication 
of  primary  amentia.  A  special  examination  with  regard  to  this 
condition  in  over  500  patients  showed  that  in  cases  presenting  . 
no  paralysis  or  other  indication  of  gross  cerebral  lesions,  and  in  Sjj 
whom  therefore  the  attacks  were  idiopathic  epilepsy,  convulsions 
occurred  in  37  per  cent.  ;  whilst  in  patients  presenting  signs  of 
gross  lesions  they  occurred  in  70  per  cent.  In  the  great  majority 
of  the~iatter,  -however,  i:he""TrEs~  were  indistinguishable  from 
ordinary  epilepsy. 


The  Clinical  Varieties  of  Primary  Amentia    191 

With  regard  to  the  degree  of  amentia,  it  was  found  that  con- 
vulsions occurred  in  11  per  cent,  of  the  feeble-minded,  42  per 
cvnt.  of  imbeciles,  and  56  per  cent,  of  idiots.  It  is  possible,^ 
however,  that  these  figures  may  be  somewhat  too  high  for 
primary  aments  in  general,  since  they  largely  relate  to  institu- 
tion patients,  and  may  therefore  contain  an  undue  proportion  of 
the  worst  cases.  Convulsions  are  most  frequent  in  the  simple 
and  microcephalic  varieties,  and  are  relatively  rare  in  the  Mon- 
golians! ~ 

With  regard  to  the  convulsions,  as  far  as  could  be  ascertained 
they  were  in  the  great  majority  of  cases  typically  epileptic,  and 
several  of  the  merely  feeble-minded  patients  have  definitely 
a|&rmed.JJia--existeace.  of  a  premonition  or  aura*  In  the  more 
severe  grades  of  defect  the  mental  condition  usually  precludes 
any  inquiry  upon  this  point,  but  trained  attendants  can  often 
foretell  the  onset  of  a  fit  by  the  appearance  of  the  patient.  Most 
of  the  attacks  are  of  the  major  variety,  although  in  a  few  cases 
minor  seizures  occur  also.  Their  severity  varies  greatly,  some 
being  of  the  mildest  possible  type7^theTs~exceedingly  severe  and 
proffacfecT  Their  frequency  is  also  subject  to  great  variation. 
IiTsome  patients  the  first  convulsion  appears  in  the  early  months 
of  life,  and  they  thence  continue  almost  daily  during  the  exist- 
ence of  the  patient.  In  other  instances,  after  frequent  fits 
during  many  weeks  or  months  of  early  childhood,  the  patient 
remains  free  for  years,  he  then  has  a  few  more,  and  these  are  again 
followed  by  years  of  quiescence.  In  yet  other  cases,  after  an 
initial  series  of  fits,  there  is  no  recurrence.  I  have  known  several 
persons  who  have  only  experienced  two  or  three  seizures  in  the 
course  of  twenty  years  or  more.  It  is  hardly  safe  to  reckon  on 
the  absence  of  epilepsy  in  any  particular  sufferer  from  primary 
amentia,  although  as  a  rule  the  fits  make  their  first  appearance 
not  later  than  the  second  decade. 

The  effect  of  the  convulsions  is  much  the  same  as  in  the 
ordinary  individual,  and  appears  on  the  whole  to  depend  upon 
the  frequency  and  severity  of  the  attacks.  If  severe  and  often 
recurring,  the  patient  rapidly  loses  even  his  hmited  acquirements  ; 
whilst  if  shght  and  seldom,  the  effect  may  be  infinitesimal. 

In  addition  to  epilepsy,  the  following  other  conditions  may  be 
mentioned  as  being  occasionally  seen  in  primary  aments  :  Chorea 


192  Mental  Deficiency 

is  not  very  common,  but  is  found  in  some  instances.  Various 
forms  of  athetosis  are  fairly  frequent  in  the  severer  grades.  In- 
tention tremor  is  occasionally  seen  ;  whilst  I  saw  at  Darenth  a  few 
years  ago  two  imbeciles  (brother  and  sister)  affected  with  a 
constant  rhythmic  tremor  of  the  whole  body,  closely  resembHng 
paralysis  agitans.  The  tremor  was  so  great  that  articulate  speech 
was  impossible  ;  the  fingers  could  not  pick  anything  up,  nor  could 
they  retain  their  hold  of  any  object.  In  each  instance  the  tendon 
reflexes  were  greatly  exaggerated,  and  ankle  and  patellar  clonus 
were  well  marked,  but  Babinsky's  sign  was  absent. 

Paralysis. — The  next  most  common  complication  is  paralysis. 
This,  like  epilepsy,  is  least  frequent  in  the  milder,  andjnQsL&<^^ 
the  severer,  grades-pf  amentia,  and,  generally  speakings  the^extent 
of  the  paralysis  is  directly  proportionate  to  the  amouiit  of  mon^tal 
"deficiency!  In  a  small  number  of  cases,  particularly  amongst  the 
microcephalics,  the  condition  is  rather  one  of  paresis  and  general 
musculai^hypotonus  and  helple55nessn:ha5l5ESr,tna,1  jj^ralysis , 
and  in  such  it  is  probably  due  to  imperfect  development  of  the 
efferent  pathway.  In  other  instances,  it  is  due  to  the  presence  of 
"a  gross  cerebral  lesion,  such  as  localized  atrophy,  porencephaly,  or 
hydrocephaly."  In  tKese~latter  the  paralysis  is  localized,  and 
varies  from  a  slight  monoplegia  to  a  severe  hemi-  or  paraplegia. 
The  affected  limbs  are  small  and  ill-nourished,  and  often  firmly 
contracted,  and  many  of  the  worst  cases  are  permanently  chair- 
or  bed-ridden.  In  a  considerable  number  of  these  cases  epileptic 
convulsions  also  occur. 

Hydrocephalus. — Probably  most  cases  of  amentia  in  which 
hydrocephalus  is  at  all  pronounced  are  of  the  secondan/Jorm,  and 
'this  condition,  as  well  as  porencephalus  and  sclerosis,  will  be  more 
fully  described  in  a  subsequent  chapter.  But  a  few  undoubted 
primary  aments  develop  hydrocephalus  with  its  characteristic 
symptoms,  and  the  condition  is  not  infrequently  found  post- 
mortem where  it  had  not  been  suspected  during  hfe. 

Porencephalus. — ^True  or  false  porencephaly  is  sometimes  found 
post-mortem  when  there  has  been  little  indication  of  its  existence 
during  hfe.  It  cannot  be  diagnosed  with  certainty,  but  its 
presence  may  be  suspected  in  cases  of  congenital  hemiplegia  which 
are  accompanied  by  considerable  non-development  of  the  affected 
limbs  and  marked  flattening  of  the  opposite  half  of  the  skull. 


The   Clinical  Varieties  of  Primary  Amentia    193 

Sclerosis. — The  usual  indications  of  this  compHcation  are 
frequently  repeated  convulsions,  followed  by  muscular  tremor, 
weaTmess,  or  acMal  paralysis  with"contractures.  In  some  cases 
there  is  persistent  headache,  the  patient  becomes  more  and  more. 
t^TTpid,  andTdies  after  a  succession  of  s^^^gieJ&tS* 

Deaf^iimtism  is  seen  in  a  small  proportion  of  primary  aments. 
It  calls  for  no  remark  beyond  the  fact  that  such  a  compUcation 
naturally  imposes  an  insuperable  barrier  to  successful  training. 
On  the  otJierJiaBdT^e  mild  mental  defect  which  results  from 
this  condition  is  greatly  ameliorated,  and  in  many  cases  removed, 
-Inappropriate  education. 


13 


CHAPTER  XIII 

SECONDARY  AMENTIA  AND  ITS  CLINICAL  VARIETIES 

Hitherto  we  have  been  concerned  with  the  primary  form  of 
amentia,  in  which  the  condition  is  due  to  an  inherent  incapacity 
^^rQormal  development  on  the  part  oi  the  embryoiiic^neuroblasts 
of  the  brain,  the  result  of  morbid  heredity. 

There  is,  however,  a  much  smaller  group  (probably  comprising 
not  more  than  about  lo  per  cent,  of  all  aments)  in  which  no  such 
intrinsic  defect  exists,  and  in  which  the  mental  defiderrcy  is 
brought  about  by  some  purely  extraneous  factor.  This  form  of 
amentia  is  termed  secondary,  and  will  now  be  considered. 

Perhaps  a  connecting  link  between  the  primary  and  secondary 
forms  is  afforded  by  that  variety  of  amentia  which  is  due  to 
epitepsy"  In  many  such  cases  morbid  heredity  is  present,  and 
^here  may  even  exist  some  of  the  stigmata  of  degeneracy  which 
are  so  characteristic  of  the  primary  form.  But  inasmuch  as 
in  these  cases  the  amentia  is  clearly  the  result  of  the  epilepsy, 
.  IJiave  considered  it  better  to  look  upon  the  mental  defect  as 
secondary,  and  we  shall  describe  it  in  this  placeT  ~ 

With  this  exception  there  is  a  marked  difference  in  the  clinical 
aspects  of  the  primary  and  secondary  forms.  The  inherent 
blight  of  the  former  gives  rise  to  numerous  and  widespread 
anomalies  of  anatomical  development  which  are  absent  in  the 
latter.  As  a  consequence,  the  sufferer  from  secondary  amentia  is 
often  readily  distinguished  from  the  primary  ament  by  being  well 
developed  and  well  grown,  and  by  his  comely  and  prepossessing 
appearance.  Occasionally,  however,  there  are  deformities  and 
abnormalities  peculiar  to  the  variety,  and  dependent  upon  the 
particular  pathological  lesion  present.  Further,  whilst  in  uncom- 
plicated cases  of  the  primary  group  the  general  tendency  is  for 

194 


Secondary  Amentia  and  its  Clinical  Varieties  195 

^ome  degree  of  amelioration  to  take  place  as  a  result  of  suitable 
training7  maiiyJ^f|those  of  the  class  we  are  now  considering  are 
tlie  result  of  cerebral  lesions  which  are  progressive,  and  the  ten- 
dency  is  rather  towards  degeneration  and  ultimate  dementia. 

In  aescribing  the  clinical  varieties  of  primary  amentia,  the 
classification  adopted  was  based  upon  the  presence  of  physiog- 
nomical characteristics.    It  is  more  convenient  to  describe~cases  oF 

"-"SBcondary  amentia  "According  to  their  particular  pathogenesis. 
From  this  standpoint  cases  of  secondary  amentia  may  con- 
veniently be  divided  into  two  main  classes.     In  the  first  of  these 
the  mental  deficiency  is  brought  about  by^  general  or  localized 

/  disease^of  the  bram^lls  ;  in  the  second  it  is  due  to  some  external 
factor  influencing  their  nutrition.  Each  of  these  classes  contains 
several  clinical  varieties.  This  chapter  will  therefore  be  divided 
into  two  sections,  as  foUows  : 

Section  I. 
Amentia  due  to  Cerebral  Disease.    /  "^- 


A 


ieties  :  (i)  Epileptic  and  eclampsic  amentia. 

(2) 

Vasctllar,    toxic,    and    inflammatory    amentia, 

including  certain  special  types,  viz.  : 

(a)  Porencephalic. 

/■' 

[b)  Sclerotic. 

f,» 

(c)   Hydrocephalic. 

Syphilitic  amentia. 

(4) 

Infantile  cerebral  degeneration. 

Section  II. 
Amentia  due  to  Defective  Cerebral  Nutrition. 

Varieties  :  (i)  Cretinism. 

(2)  Amentia  due  to  nutritional  defect. 

(3)  Amentia  due  to  sense  deprivation. 

It  may  be  well  again  to  emphasize  the  fact  that,  although  many 
of  the  etiological  and  pathological  conditions  present  in  secondary 
amentia  may,  and  frequently  do,  complicate  the  primary  form,  we 
are  only  here  concerned  with  such  cases  of  amentia  as  are  directly 
and  entirely  attributable  to  them. 


^1  „  -:j  <  .J^  /•  ;•  J 


196  Mental  Deficiency 

Section  I. 

AMENTIA  DUE  TO  CEREBRAL  DISEASE. 

In  this  class  the  morbid  anatomy  consists  of  a  (usually)  localized 
arrest  of  neuronic  development,  which  in  most  instances  is  accom- 
panied- by'  lesions  obvious  to  the  naked  eye.  In  a  "considerable 
number  of  cases  degenerative  changes  supervene,  in  consequence 
of  which  dementia  becomes  added  to  the  mental  deficiency. 

EPILEPriC  AND  ECLAMPSIC  AMENTIA. 

It  used  to  be  the  custom,  in  describing  the  varieties  of  amentia, 
to  group  together  into  one  class  all  those  persons  who  were,  or 
had  been,  subject  to  epileptic  or  similar  convulsions,  and  to  label 
them  "  epileptic  "  or  "  eclampsic  "  aments.  A  close  examination 
of  this  class,  however,  shows  that  it  is  really  a  most  heterogeneous 
collection. 

It  is,  perhaps,  not  unnatural  that  the  parents  should  see  in 
these  convulsions  the  reason  and  cause  of  the  mental  deficiency 
of  their  child,  and,  as  a  matter  of  fact,  there  is  no  other  single 
etiological  factor  which  is  so  frequently  advanced  as  the  "  cause." 
To  the  lay  mind  "  fits  "  are  both  impressive-and  alarming^  It  is 
not  surprising  that  even  medical  practitioners  should  frequently 
be  satisfied  with  this  explanation,  for  they  are  fully  aware  of  the 
mental  hebetude  and  degeneration  which  may  supervene  upon 
epilepsy.  But  I  am  convinced,  from  the  examination  of  some 
hundreds  of  aments  suffering  from  epilepsy,  as  well  as  from  careful 
inquiries  into  their  family  and  previous  personal  history,  that  in 
the  great  majority  no  such  causal  relationship  exists  as  is  implied 
by  the  term  "  epileptic." 

The  relationship  existing  between  epilepsy*  and  amentia  is  of 
three  kinds,  as  follows  : 

I.  Primary  Amentia  in  which  Epilepsy  occurs  as  a  Mere  Com- 
plication.— This  has  already  been  considered  in  the  chapter  deaUng 
with  the  complications  of  primary  amentia  (p.  190). 

♦  For  convenience,  the  term  "  epilepsy  "  is  here  used  to  include  epilepti- 
form as  well  as  epileptic  (idiopathic)  convulsions. 


Secondary  Amentia  and  its  Clinical  Varieties  197 A 

2.  Idiopathic  Epilepsy  or  Eclampsia  causing  Amentia. — It  is 
with  this  group  that  the  present  account  deals. 

3.  Gross  Cerebral  Lesions  causing  Epilepsy  and  Amentia. — Here 
both  the  epilepsy  and  amentia  are  symptomatic  of  conditions 
which  will  be  described  in  subsequent  pages. 

The  following  table  shows  the  chief  points  of  difference  between 
these  three  groups  in  which  amentia  and  epilepsy  co -exist  : 

TABLE  XV. 

Showing  the  Relation  of  Epilepsy  to  Amentia. 


Morbid  heredity 

Condition  of 
patient  before 
the  fits 


Nature  of  fits 


Condition 
patient 


of 
after 
fits  have  made 
their  appear- 
ance 


Stigmata  of  de- 
generacy 


Group  i. 
Primary  amentia  com- 
plicated by  epilepsy. 


Pronounced 

Some  degree  of 
amentia  or  general 
backwardness  usu- 
ally noticed 

Epileptic.  Usually 
milder  and  less  fre- 
quent than  Group  2 

Degree  of  amentia 
ofit-n  much  greater 
than  would  be  ac- 
counted for  by  the 
severity  and  fre- 
quency of  fits 

Paralysis  may  be  pre- 
sent also  if  a  gross 
lesion  co-exists 

Marked  (except  in 
highest  grades) 


Prospects  of  im-  Dependent  upon  se- 
prove  mem  j  verily  and  fre- 
under  special  i  quency  of  fits,  but 
training  on  the  whole  better 

than    in    Groups  2 

and  3 


Group  2. 

Secondary  amentia^ 

due  to  idiopathic 

epilepsy. 


Less  pronounced 
Normal 


Epileptic, 
vere    and 
quent 


Se- 
fre- 


Amentia  usually 
mild,  but  much 
dementia 


No  paralysis 


Slight 


Practically  none 


Group  3. 

Secondary  amentia  and 

epilepsy  A\x^  to  gross 

cerebral  disease. 


Absent 

Normal.  Onset  of  fits 
can  generally  be  traced 
to  some  definite  morbid 
process  affecting  brain 

Epileptic.  Occasionally 
epileptiform ;  rarely  con-^ 
Slant,  rhythmic  tremor 

Considerable  amentia 
may  be  present  with 
mild  and  infrequent  fits 


Paralysis  often  present 


Absent 


Dependent  upon  time  of 
occurrence,  site,  extent, 
and  nature  of  lesion, 
and  upon  severity  and 
frequency  of  fits.  Usu- 
ally intermediate  be- 
tween Groups  I  and  2 


Epileptic  Amentia. — It  is  common  knowledge  that  frequently 
repeated  severe  convulsions,  or  even  minor  attacks,  occurring  in  a 
person  of  mature  cerebral  development  may  give  rise  to  dementia. 
The__anatomical  basis  of  this  conditionisa^degeneration  of  the 
same  cortical  cells"and  fibres  as  are  imperfectly  developed  in 


198  Mental  Deficiency 

amentia.*  If  the  development  of  these  neurones  is  as  yet  incom- 
plete, as  in  the  infant,  it  may  be  irremediably  arrested,  and  a 
condition  of  secondary  mental  deficiency  result.  For  the  pro- 
duction of  amentia,  then,  in  addition  to  the  factors  which  produce 
dementia,  the  cohvuTsioiisniust  occur  during  the  first  few  yeafs^df 
hfe.  This  is  the  case  in  a  considerable  proportion  of  epileptics, 
and  Sir  William  Gowersf  states  that  in  12 '5  per  cent,  of  cases  the 
convulsions  make  their  first  appearance  before  the  age  of  three 
years.  In  such  cases  the  mental  development  of  the  patient  may 
become  arrested,  so  that  whilst  his  body  develops  his  mind  is  no 
more  advanced  than  that  of  an  idiot,  imbecile,  or  feeble-minded 
person.  Savage  makes  the  statement  that  epilepsy  "  occurring 
before  seven  years  of  age  is  certain  to  leave  the  patient  weak- 
rniMed  ";  but  I  am  inclined  to  think  that,  if  by  weak-mindedness 
is  meant  amentia,  this  is  a  little  too  sweeping.  Nevertheless,  some 
degree  of  amentia  does  certainly  result  in  many  cases  of  epilepsy 
beginning  thus  early.  On  the  other  hand,  the  proportion  of  aments 
who  owe  their  condition  to  this  cause,  and  who  are  truly  sufferers 
from  epileptic  amentia,  is  a  small  one.  In  my  own  series  of  cases 
I  find  that  3*5  per  cent,  only  of  aments  belong  to  this  variety,  but 
this  number  must  be  regarded  as  merely  an  approximate  estimate. 
The  pathology  of  these  cases  has  already  been  described  ;  it  is 
usually  that  of  arrested  neuronic  development  plus  degeneration. 

Epileptic  aments  differ  considerably  in  their  clinical  features. 
In  some  the  bodily  condition  is  sufficiently  unlike  to  be  readily 
distinguishable  from  ordinary  primary  aments  ;  but  there  are 
others  who  so  closely  resemble  that  class  that  a  diagnosis  can  only 
be  made  by  most  careful  attention  to  the  history  and  the  capacity 
of  the  patient  prior  to  the  onset  of  the  fits.  It  may  be  stated  that, 
as  a  general  rule,  epileptic  aments  are  better  grown  anddeveloped, 
and  possess  fewer  of  tfag^igmata  which  are  such  a  conspicuous 
jeature^f  the  primary  group.  • 

The  degree  of  mental  deficiency  varies  from  a  mild  amount  of 
feeble -mindedness  to  a  state  resembling  idiocy  ;  but  this  latter 
conditijon  is  more  often  the  result  of "arsuperadded  dementia  than 
of  a  purelnentararfest."^n  the  milder  cases,  although  the  patients 

♦  This  has  been  recently  shown  in  J.  S.  Bolton's  exhaustive  work, 
"  Amentia  and  Dementia,"  Journal  of  Mental  Science,  1905  et  seq. 

t  Sir  W.  R.  Gowers'  article  "Epilepsy,"  in  Clifford  Allbutt's  "System 
of  Medicine,"  vol.  vii. 


Secondary  Amentia  and  its  Clinical  Varieties  199 

rarely  make  much  headway  with  school  learning,  a  certain  amount 
of  manual  training  is  possible,  and  many  of  them  are  able  to  do 
more  or  less  useful  work.  But  the  persistence  of  the  fits  gradu- 
ally strips  these  persons  of  any  acquirements  they  may  have  pos- 
sessed, and  in  the  majority  of  cases  dementia  is  but  a  question  of 
time.  On  the  whole,  it  may  be  said  that  the  prospects  of  ameliora- 
tion by  training  and  the  general  prognosis  of  this  class  are  of  the 
most  unfavourable  description.  There  are  a  few  cases  of  epileptic 
amentialn  wnicn  the  tits  cease,  and  in  these  the  mental  condition 
may  miprove  very  considerably.  There  are  other  cases  in  which 
a  diminution  of  the  fits  and  some  degree  of  mental  improvement 
takes  place,  apparently  in  consequence  of  medicinal  treatment  and 
regimen  ;  but  these  cases  are  decidedly  exceptional,  and  in  no 
instance  is  real  mental  deficiency,  once  produced,  ever  overcome. 

There  is  one  mental  feature  which  is  common  to  most  of  these 
cases,  and  that  is,  a  general  irritability  and  intractability.  Epi- 
leptic aments  are  often  exceedingly  stubborn  and  difficult  to 
nia,liage  ;  they  are  prone  to  sudden  outbursts  of  temper  and 
violence,  and  they  are,  in  fact,  probably  the  most  untrustworthy 
^;;^ll_thg_yaj^i^ties-of~fn^ital  deficiency. 

With  regard  to  the  fits  themselves  there  is  little  to  be  said.  They 
may  be  of  either  the  minor  or  major  variety,  or  of  both.  They 
are  occasionally  preceded  by  a  definite  aura,  or  by  some  recog- 
nizable alteration  in  the  appearance  of  the  patient,  and  they  are 
usually  followed  by  a  varying  period  of  intellectual,  sensory,  and, 
at  times,  motor  exhaustion,  transient  paresis  being  by  no  means 
uncommon.  In  a  certain  number  of  cases  they  seem  to  be 
directly  excited  by  indigestion,  constipation,  undue  excitement,  or 
some  determinate  cause  ;  in  others  they  occur  independently  of 
any  ascertainable  factor.  The  frequency  of  some  is  diminished 
by  dieting,  careful  regulation  of  the  daily  life,  and  the  administra- 
tion of  drugs,  of  which  the  most  valuable  are  stilljthe  brgmideg. 
In  many  cases,  however,  the  fits  persist  in  spite  of  all  treatment, 
and  hopeless  dementia  results. 

Illustrative  Cases. 
L.  J.,  male,  the  fourth  born  of   a  family  of  eight,  of  whom 
three  only  are  now  ahve  ;  the  remaining  five  died  in  infancy,  and 
all  of  them  were  subject  to  convulsions.     The  patient's  father 


200  Mental  Deficiency 

was  strongly  addicted  to  alcohol,  and  died  at  the  age  of  forty- 
seven,  cause  unknown  ;  his  father's  father  died  aged  fifty-seven, 
and  was  paralyzed  for  six  years  before  death.  The  patient's 
mother  is  alive  and  in  tolerably  good  health  ;  she  had  thirteen 
brothers  and  sisters,  all  of  whom  are  dead,  several  of  consumption, 
and  her  father  died  aged  fifty,  of  asthma. 

The  patient  had  fits  when  a  month  old,  and  they  have  con- 
tinued on  and  off  ever  since.  During  infancy  he  used  to  have  as 
many  as  ten  daily.  With  the  exception  of  the  fits,  he  was  not 
noticed  to  be  different  to  other  children  until  schoohng  began. 
He  was  then  found  unable  to  make  any  progress,  and  after  a 
short  time  was  discharged.  He  remained  at  home  pottering 
about,  but  doing  no  regular  work,  until  seventeen  years  of  age, 
when  he  became  so  unmanageable  that  he  had  to  be  sent  to  an 
asylum.  On  admission  he  was  a  pale-faced,  somewhat  undersized 
youth,  with  slight  stigmata  of  degeneracy.  He  was  dull  of  com- 
prehension, and  slow  in  realizing  what  was  said  to  him.  Memory 
very  defective,  and  in  replying  to  questions  he  would  constantly 
repeat  himself.  Able  to  draw  a  little,  but  unable  to  read,  write, 
or  sum,  and  decidedly  feeble-minded.  He  was  liable  to  attacks 
of  violence  before  the  fits,  and  would  then  attack  anyone  who 
might  be  near  him.  After  the  fits  he  remained  heavy  and 
stuporose  for  a  day  or  more.  He  admitted  that  he  was  excited 
before  the  fits,  and  said  it  came  over  him  '*  all  of  a  sudden."  He 
complained  a  good  deal  of  headache.  He  remained  in  practically 
the  same  condition,  having  fits  at  the  rate  of  three  or  four  weekly, 
and  being  either  too  excitable  or  too  stuporose  to  do  any  work. 
He  is  now,  at  the  age  of  twenty,  showing  signs  of  dementia.  (See 
Plate  XV.,  Fig.  39.) 

F.  S.,  female,  the  eighth  of  a  family  of  thirteen,  three  of  whom 
are  dead,  the  remainder  living,  and  said  to  be  in  good  health. 
The  father  has  been  insane  in  an  asylum.  The  patient  had 
severe  fits  whilst  cutting  her  teeth,  and  they  recurred  almost 
daily  until  she  was  five  years  old.  Since  then  they  have  only 
returned  at  rare  intervals.  She  always  seemed  idiotic,  had  no 
idea  of  playing  like  the  other  children,  and  received  no  education 
of  any  kind.  She  remained  at  home  until  in  her  teens,  but  was  a 
great  trouble,  being  unable  to  speak  or  look  after  herself  in  any 
way.     She  would  wander  aimlessly  about  the  house,  and  was 


Plate  XV. 


To  face  page  200.] 


Secondary  Amentia  and  its  Clinical  Varieties  201 

generally  very  restless  ;  if  left  alone  would  be  sure  to  get  into 
trouble,  and  was  occasionally  violent  and  aggressive.  She 
finally  became  so  unmanageable  that  she  had  to  be  sent  to  an 
asylum. 

On  admission  she  was  found  to  be  a  pronounced  idiot.  She 
had  no  understanding  of  what  was  said  to  her,  and  was  unable 
to  articulate.  She  spent  the  day  sitting  in  a  chair  rocking  herself 
to  and  fro,  and  occasionally  screaming  or  making  a  grunting 
noise.  She  had  no  idea  of  personal  cleanliness,  and  had  to  be  fed 
with  a  spoon.  She  destroyed  everything  she  could  lay  her  hands 
on.  At  the  present  time  she  is  twenty-seven  years  of  age,  and 
her  condition  is  practically  unchanged.  She  has  had  a  few 
epileptic  fits  at  rare  intervals,  the  longest  period  of  intermission 
being  four  years. 

To  these  two  examples  many  others  might  be  added,  but  they 
are  sufficient  to  illustrate  the  unfavourable  type  of  amentia 
which  may  result  from  severe  epilepsy  in  early  life.  The  effect, 
as  already  remarked,  is  not  always  so  serious,  and  I  know 
several  instances  in  which  but  a  mild  degree  of  mental  deficiency 
has  been  produced,  and  where  more  or  less  continuous  occupa- 
tion is  possible.  But  I  think  these  latter  cases  are  exceptional. 
There  is  no  doubt  that  the  prospect  of  improvement  is  greatest 
whfff^  th?'rnn\ml"iirm^  can  be  reHevMl)yTfea±[Ttent;-~and  hence 
the  importance  of  careful  medical  supervision  of  these  cases. 
Into  the  question  of  treatment  I  do  not  propose  to  enter,  since 
it  is  that  oi  ordinary  epilepsy.  It  may,  however,  be  stated  that 
attentioQ^to  the  diet  and  the  ordering  of  the  daily  life  are  of  the 
utmost  importance,  whilst  of  drugs  the  bromides,  in  combination 
with  borax,  will  usually  be  found  the  most  efficacious . 

Eclampsic  Amentia..— Instability  of  the  nerve  cells  of  the  brain 
islTnormai  characterisTicof  infancy,  and  is  probably  in  no  small 
measure  due  to  the  rapid  growth  which  takes  place  during  the  early 
months  of  life.  At  the  end  of  the  first  year  the  brain  weighs  three 
times  as  much  as  it  did  atbirtli.  As  a  consequence'Ttlereis  no 
doubt  that  the  child  is  much  more  predisposed  to  convulsions  than 
is  the  adult  ;  but  although  convulsions  are  exceedingly  common  in 
infancy,  I  am  of  opinion  that  no  ordinary  excitant  will  produce 
them  in  a  healthy  child  of  good  heredity.  Where  they  occur, 
there  is  either  some  special  inherited  predisposition,  or  else  the 


202  Mental  Deficiency 

natural  instability  has  been  markedly  exaggerated  by  a  dis- 
turbance of  cerebral  nutrition  caused  by  bodily  ill-health.  Where 
this  special  predisposition  exists,  such  simple  exciting  factors  as 
acute  indigestion,  constipation,  dentition,  or  the  ordinary  febrile 
ailments  of  childhood,  will  suffice  to  determine  convulsions. 
Where  no  predisposition  is  inherited,  it  may  be  acquired  in  con- 
sequence of  anaemia,  malnutrition,  chronic  disturbances  of  the 

alimentary -tract^aTid,  above  all,  rickets.      """"" '  " 

^  Itis  thus  seen  that,  theoretically,  infantile  convulsions  fall  into 
two  groups — those  which  are  the  result  of  ^jx-inhcritod  predjs- 
position,  and  those  m  which  the  tendency  is  acquired.  The 
former  must  be  considered  as  undoubtedly  identical  with  idio- 
pathic epilepsy,  and  they  often  persist  throughout  life  ;  fhe  latter 
group  are  eclanip§ic_only.  But  it  is  not  uncommon  for  convul- 
sions which  have  been  looked  upon  as  simply  eclampsic  to  recur, 
and  to  persist  with  all  the  features  of  true  epilepsy  ;  consequently 
the  division  between  these  two  conditions  is  one  which  is  exceed- 
ingly difficult,  and  at  times  impossible,  to  draw.* 

Thojterm  "  eclampsic  amentia  "  should,  of  course,  be  limited  to 
those  cases  of  mental  deficiency  which  are  clearly'^h^Te^Tf  of 
simple  infantile  convulsions  due  to  this  acquired  predispogition. 
Such  a  result,  in  my  opinion,  seldom~occurs,  lor  in  the  great 
majority  of  children  who  thus  suffer  from  a  series  of  fits  which  do 
not  recur,  there  is  no  permanent  impairment  of  the  mental 
faculties.  In  a  few  cases,  however,  some  degree  of  amentia  does 
result,  but,  as  this  is  in  all  probability  dependent  upon  a  definite 
vascular  or  toxic  lesion  of  the  brain,  it  seems  more  desirable  to 
includF<ecTampsic' cases  under  these  headings. 

*  It  is  of  interest  to  note  that  Dr.  R.  O.  Moon,  as  a  result  of  his  examina- 
tion of  200  cases  of  convulsions  in  children,  says  :  "  I  have  not  been  able 
to  find  any  clear  dividing-line  between  infantile  convulsions  or  eclampsia 
on  the  one  hand,  and  idiopathic  epilepsy  on  the  other.  .  .  .  On  the  con- 
trary, it  has  seemed  to  me  that  convulsions  in  early  life  may  shade  off 
indefinitely  into  epilepsy  or  epileptiform  manifestations,  so  that  it  becomes 
often  impossible  to  say  where  the  one  stops  and  the  other  begins." — 
"  Some  Observations  on  Convulsions  in  Children,  and  their  Relation  to 
Epilepsy"  {Lancet,  September  15,  1906). 


Secondary  Amentia  and  its  Clinical  Varieties  203 


VASCULAR,  TOXIC,  AND  INFLAMMATORY  AMENTIA. 

It  is  by  no  means  uncommon  for  symptoms  indicative  of  a 
morbid  state  of  the  brain  or  its  membranes  to  occur  in  childhood. 
Such  cerebral  symptoms  may  be  due  to  injuries  received  during 
birth  ;  they  may  arise  during,  or  subsequent  to,  one  of  the 
specific  fevers  ;  they  may  follow  a  chronic  inflammation  of  the 
nose  or  middle  ear ;  or  they  may  occur  entirely  apart  from  any 
other  illness.  It  is  probable  that  a  large  number  of  the  children 
in  whom  such  symptoms  are  at  all  severe,  die.  Others,  but  rela- 
tively few,  appear  to  make  a  complete  recovery.  In  yet  others 
_death  does_not_take  place,  but  a  permanent  legacy  remains  in  the 
shape  of  a  gross  cerebral  lesion.  ) 

^"THe^ chief  of  these  causes  may  be  enumerated  as  asphyxia' 
neonatorum  and  trauma  (occurring  before,  during,  or  after  birth) ; 
sc'krlet  fe^ei",  measles,  small-pox,  enteric,  whooping-cough,  otitis, 
rhinitis,  and  possibly  sunstroke  ;  lastly,  primary  inflammation  — 
of  the  cortical  cells  (polio-encephalitis  of  Striimpell),  a  disease 
.^n-alogous  to  the  acute  inflanima?fi3TrTrct'urrmg  m  tEe  anterior 
horns  of  the  spinal  cord.  This  last  condition  is  probably  a  toxic 
one,  and  is  the  one  of  most  importance.  It  is  probably  the  under- 
lying-eoftdi^rroir-t^f-rrrOSt^Tasc!^^  of  cerebral  origin 
occurring  in  infancy,  as  well  as  of  many  in  which  brain  symptoms 
are  attributed  to  sunstroke  and  other  vague  causes. 

The  lesions  which  result  from  these  varied  causes  are,  broadly 
speaking,  divisible  into  two  classes — vascular  and  toxic.  The 
|former  group  embraces  haemorrhage,  tlTromDosis,  and  occasion- 
ally embolus,  with,  it  may  be,  laceration  of  brain  tissue.  The 
latter  group  consists  of  cases  in  which  there  is  a  direct  poisoning 
of  the  nerve  cells.  But  in  many  instances  both  these  conditions 
are  present. 

In  course  of  time  secondary  changes  take  place  in  and  around 
the  initial  lesion,  so  that  the  final  product  is  often  very  different 
to  the  change  in  the  first  instance.  The  chief  ultimate  results, 
as  seen  in  post-mortem  examinations  made  many  years  after- 
wards, are  localized  areas  of  softening,  atrophy,  and  sclerosis  ; 
cysts,  meningo-encephalitis,  pseudo-porencephaly  or  hemi- 
atrophy, and  occasionally  hydrocephaly.  In  these  later  stages  it 
is  usually  impossible  to  say  whether  the  original  lesion  was 


04  Mental  Deficiency 


vascular,  toxic,  or  inflammatory,  and  as  there  are  no  characteristic, 
cHnical  differences  I  see  no  object  in  treating  of  these  as  separate 
varieties  ;  they  will  therefore  be  considered  together. 

But  it  is  not  to  be  assumed  that  the  child  who  emerges  from  an 
illness  of  this  kind  with  a  gross  lesion  of  the  brain  will  necessarily 
be  mentally  defective.  "The  efiect  of  the  lesion  upoirfhe  patient 
vaTTeS"^very  much,  and  in  the  main  three  phenomena  may  result, 
either  singly  or  in  combination — namely,  i)aralysis,  ei>il^s:^r  said 
amentia. 

TTis'  stated  that  if  paralysis  results  from  these  lesions  it  is  sure 
to  be  accompanied  by  some  amount  of  mental  deficiency.  This 
is  a  complete  mistake  ;  not  only  may  amentia  occur  without 
paralysis,  but  marked  paralysis  may  be  present  witir(5ut"ainentia. 
I  have  seen  quite  a  considerable  number  of  cases  m  which  there 
was  paralysis  of  hand  and  forearm  or  foot  and  leg,  or  even  of  two 
limbs,  without  the  slightest  intellectual  impairment  ;  ji^jdeed,  in 
soffie  of  'the"in  ^Ke^  mental"  Ifapacit^  above  the 

average.  Dr.  Sigmund  Freud,*  who  has  made  -arrrtost- cSifeful 
study  of  the  question,  says  :  "  Idiocy  does  not  show  any  constant 
relationship  to  the  other  signs  of  infantile  cerebral  paralysis  in 
respect  of  the  degree  of  psychic  arrest.  There  are  cases  of  the 
severest  paralysis  with  the  intelligence  scarcely  affected,  as,  on 
the  other  hand,  complete  idiots  without  any  signs  of  paralysis." 

With  regard  to  epilepsy  the  case  is  somewhat  different,  and 
where  the  initial  pathological  process  is  such  as  to  produce 
frequently  repeated  convulsions,  there  is  a  strong  probability  that 
some  degree  of  amentia  will  result,  and  that  dementia  will  ulti- 
mately supervene.  But  in  these  cases  this  result  is  by  no  means 
invariable,  and  it  occasionally  happens  even  in  them  for  intel- 
lectual development  to  show  no  sign  whatever  of  having  been 
adversely  affected.  In  exceptional  cases  it  may  even  happen  for 
the  mind  to  show  no  trace  of  defect  where  both  paralysis  and 
epilepsy  are  present. t    Finally,  in  a  certain  number  of  cases 

*  Freud,  "  Infantile  Cerebrallahmung,"  Wien,  1897. 

t  A  good  example  of  this  was  described  by  the  writer  in  an  article  on 
"  Amentia"  in  Mott's  "Archives  of  Neurology,"  vol.  ii.  In  this  case  there 
was  right  hemiplegia,  with  constant  epileptic  fits  from  birth,  probably  due 
to  asphyxia  neonatorum.  The  patient  died,  aged  thirty-five  years,  from 
exhaustion  following  a  series  of  fits,  and  post-mortem  examination  revealed 


Secondary  Amentia  and  its  Clinical  Varieties  205 

these  infantile  lesions  give  rise  to  amentia,  and  this  may  be 
g^companied  by  either  paralysis  or  epilepsy,  by  both,  or — - 
neither.  It  is  thus  seen  that  these  infantile  cerebral  lesions  are 
attended  with  widely  different  results,  and  although  in  this  place, 
of  course,  we  are  only  concerned  with  those  in  which  amentia  occurs, 
it  will  not  be  out  of  place  to  consider  the  reason  for  such  diversity. 
Two  possible  factors  influencing  the  result  are  the  age  of  the 
patient  when  the  lesion  occurs  and  the  inherited  potentiality  of 
the  neuroblasts.  In  the  new-born  child  cortical  lamination  is 
not  yet  complete,  and  there  are  a  large  number  of  neuroblasts 
lying  among  more  fully  developed  nerve  cells.  I  am  inclined  to 
think  that  a  considerable  number  of  these  never  attain  mature 
development,  for  such  immature  cells  may  often  be  found  in 
middle  life.  In  this,  as  in  other  matters,  Nature  seems  to  act 
lavishly,  and  to  provide  a  far  greater  number  of  cells  than  are 
developed  by  the  stimulus  of  incoming  sensations  which  comprise 
"  education."  In  fact,  there  appears  to  be  a  potentiality  of 
cerebral  development  which  is  never  attained  by  the  individual ; 
although  it  is  probably  to  the  gradual  bringing  into  play  of  these 
neuroblasts  that  the  progressive  mental  evolution  of  the  race  is 
due.  With  the  lapse  of  years,  doubtless,  the  developmental 
capacity  of  these  embryonic  cells  becomes  progressively  less,  and 
hence  the  older  the  child  the  more  serious  is  likely  to  h^  f|i^  _. 
result  of  one  of  these  lesions.  Before  cortical  lamination  is 
complete,  howeverj__Isee  no  reason  why  their  inherent  j^oten- 
tiaIrEy"sliouidbe  inferior  to  otners  amid,  which  they  lie.  Conse- 
quently it  is  not  improbable  that  the  destruction  of  nerve  cells 
caused  by  a  lesion  occurring  at  or  shortly  after  birth  may  be 

chronic  meningo-encephalitis  of  the  whole  of  the  motor  region  of  the  left 
hemisphere.  There  was  also  considerable  non-development  of  this  hemi- 
sphere, its  weight  being  105  grammes  less  than  the  right,  and  there  was 
chronic  interstitial  sclerosis,  with  diminished  number  of  nerve  fibres, 
throughout  the  corresponding  upper  efferent  tract.  The  motor  lesion  had 
been  compensated  to  a  great  extent  by  a  numerical  increase  of  Betz'  cells 
of  the  opposite  hemisphere.  And  yet  this  patient  showed  no  trace  of 
amentia,  and,  in  spite  of  his  paralysis  and  epilepsy,  was  able  to  earn  his 
living  until  nearly  twenty  years  of  age.  He  was  then  admitted  to  the 
workhouse  in  consequence  of  the  fits,  and  subsequently  transferred  to  the 
asylum  on  account  of  post-epileptic  insanity.  At  the  time  of  his  death 
there  was  practically  no  dementia. 


2o6  Mental  Deficiency 

compensated  by  the  development  of  these  embryonic  cells  ; 
and  where  the  two  hemispheres  have  a  function  in  common, 
it  may  even  be  possible  for  such  compensation  to  take  place  in 
the  opposite  side  to  the  one  affected.  This  view,  of  course,  is 
largely  hypothetical,  but  it  finds  support  in  a  number  of  clinical 
facts  which  are  otherwise  extremely  puzzling.  Thus,  many  cases 
have  been  recorded  in  which  the  greater  part  of  one  cerebral 
hemisphere  was  practically  useless  by  reason  of  porencephaly  or 
hemiatrophy,  and  yet  the  mental  and  motor  defect  was  but 
slight  ;  indeed,  in  a  large  number  of  these  cases  the  clinical  signs 
(particularly  of  paralysis)  are  astonishingly  insignificant  when 
compared  with  the  state  of  the  encephalon.*  Moreover,  in  the 
case  already  referred  to,  where  practically  all  the  large  motor 
cells  (of  Betz)  of  the  left  leg  area  hadbeen  destroyed  by  a  vascular 
l^on  during  birth,  I  was  able  tooemOiisti'ttte  a  LuniptnsalOTy" 
increa^  in  the  corresponding  cells  of  the  opposite  hemisphere. 

A  diminished  neuronic  potentiality,  due  to  slight  morbid 
heredity,  is  the  explanation  of  those  cases  of  so-called  '*  develop- 
mental" amentia  which  apparently  result  from  a  compara- 
tively trifling  cerebral  lesion  or  general  disturbance  of  health, 
and  in  all  probability  in  the  cases  we  are  now  considering  the 
effect  of  these  lesions  upon  the  intellectual  capacity  of  the 
patient  is  in  no  little  measure  influenced  by  his  hereditary  pre- 
disposition. One  would  also  imagine  that  the  ultimate  amount 
of  physical  or  psychic  impairment  in  these  cases  would  be  con- 
siderably influenced  by  the  amount  of  special  training  received 
by  the  patient  during  infancy. 

*  On  this  subject  see  a  very  interesting  article  on  "  Secondary  Degenera- 
tion following  Cerebral  Lesions,"  by  W.  G.  Spiller  {Journal  of  Nervous 
and  Mental  Disease,  New  York,  January,  1898).  Dr.  Spiller  describes  the 
case  of  a  boy  in  whom  "  the  motor  fibres  of  the  left  cerebral  hemisphere 
were  totally  destroyed,  and  yet  the  boy  was  able  to  walk  without  a  crutch, 
although  in  an  imperfect  manner  ;  he  had  no  use  of  the  right  upper  limb." 
Spiller  says  :  "  The  conviction  is  forced  upon  one  that  the  motor  fibres 
to  the  right  lower  limb  were  transmitted  through  the  pyramidal  fibres 
from  the  right  cerebral  hemisphere.  .  .  .  The  nervous  system  can  adapt 
itself  much  better  to  altered  circumstances  if  destruction  of  tissue  occurs 
before  the  nerve-cells  and  fibres  are  fully  formed,  and  it  would  seem 
that  even  additional  fibres  may  develop."  He  quotes  several  similar 
cases  whichjhave]  been  recorded  by  von  Monakow,  Mahaim,  D6jdrine, 
Thomas,  and  Zacher. 


Secondary  Amentia  and  its  Clinical  Varieties  207 

With  regard  to  the  kind  of  lesion,  Freud  doubts  whether  it  is  a 
factor  of  much  importance.  He  says  :  "  One  is  as  hkely  to  see  a 
brain  with  diffuse  lobular  sclerosis,  with  extensive  blood-cysts, 
porencephaly,  and  the  like,  whether  the  individual  was  idiotic  or 
relatively  well  developed  mentally."  I  cannot  but  think,  how- 
ever, that  in  many  cases  the  secondary  changes  taking  place  in 
and  around  the  diseased  focus  have  contributed  not  a  little  to  the 
patient's  mental  state.  Some  of  the  initial  lesions  tend  to  become 
locaUzed  and  shut  off,  others  to  spread  and  cause  diffuse  changes, 
and  it  seems  to  me  that  such  differences,  probably  by  bringing 
about  alterations  of  intracranial  pressure,  cannot  be  without 
effect  upon  the  general  brain  function,  and  therefore  the  mental 
capacity. 

But  undoubtedly  the  most  important  feature  of  these  lesions  is 
their  situation  and  extent.  If  confined  to  the  motor  cortex  or  its 
downward  prolongations,  the  result  will  probably  be  paralysis 
without  amentia.  In  a  considerable  number  of  cases,  however, 
lesions  ot  the  motor  cortex  also  produce  convulsions  which  may  at 
first  be  Jacksonian,  and  ultimately  become  typically  epileptic. 
fay  even  happen  for  a  subcortical  focus  of  disease  to  produce 
similar  convulsions.*  As  a  consequence  amentia  and  dementia 
may  be  induced.  A  lesion  in  or  near  the  motor  cortex  may  excep- 
tionally cause  epilepsy  without  paralysis,  and  here  also  the  convul- 
sions may  bring  about  subsequent  mental  deterioration  ;  in  such 
cases  paralysis  may  supervene  later.  A  lesion  elsewhere  may  give 
rise  to  epilepsy,  either  by  acting  as  a  source  of  reflex  irritation,  or 
by  causing  an  increased  intracranial  pressure.  Finally,  a  lesion 
of  the  more  purely  psychic  areas  (probably  the  frontal,  prefrontal, 
and  parietal  lobules)  may  produce  amentia  without  either 
paralysis  or  epilepsy.  It  is  necessary  to  remember  that  not  only 
may  secondary  pathological  changes  be  induced  by  any  of  these 
lesions,  but  that  an  arrest  of  development  may  occur  in  far 
removed  portions  of  the  encephalon  which  are  fimctionally 
correlated.  The  involvement  of  both  hemispheres,  as  shown  by 
a  paraplegia,  is  of  far  more  serious  import  than  where  one  side 
only  is  affected. 

To  sum  up,  we  may  say  that  a  severe  lesion  of  the  psychic  \ 

*  Such  a  case  was  described  by  the  author  in  Mott's   "  Archives  of  ^ 
Neurology,"  vol.  i. 


2o8  Mental  Deficiency 

axeas^-wi^^ probablY_  produce  amentia  without  paralysis,  and  a 
lesion  of  the  motor  areas  paralysis  without  amentia.  But  either 
'oT'these  may~give  risF  to  epilepsy,  and  this  may  also  result  from 
M  ^ginrTpk^y/hp-rp.  As  a  result  of  this  epilepsy,  amentia,  and  sub- 
sequent dementia,  may  be  induced. 

The  clinical  symptoms  which  usher  in  these  cerebral  comphca- 
tions  differ  somewhat  according  to  the  particular  cause.  In  the 
cases  due  to  injury  during  birth,  well-marked  asphyxia  is  often 
present,  from  which  the  child  is  with  difficulty  resuscitated.  He 
remains  torpid,  respiration  is  apt  to  be  slow  and  irregular,  and 
the  pulse  is  feeble.  The  pupils  may  be  contracted,  and  the 
anterior  fontanelle  tense.  He  does  not  cry,  and  evinces  little 
interest  in  the  breast.  Usually  in  a  few  days  convulsions  make 
their  appearance ;  but  in  between  these  the  muscles  may  still 
remain  rigid,  and  opisthotonos  may  even  be  present.  At  a  some- 
what later  period  paralysis  may  be  noticed.  Sitting  up,  walking, 
and  first  attempts  at  speech,  are  all  delayed,  and  it  is  gradually 
borne  in  upon  the  parents  that  the  child's  mind  is  not  quite  the 
same  as  that  of  other  children.  In  the  milder  cases  the  initial 
symptoms  may  rapidly  pass  off,  and  it  is  only  when  the  child 
begins  his  schooling  that  deficiency  is  noticed,  and  that  he  is 
found  to  be  unable  to  make  any  mental  effort. 

Many  of  these  children  are  small  and  delicate,  and  there  is  no 
doubt  that  a  large  proportion  die  in  the  early  years  of  life,  some  of 
convulsions,  others  of  ordinary  children's  ailments.  But  others 
thrive  and  get  fat,  and  may  live  for  many  years ;  and  it  is  these 
who  coriie  under  notice  on  account  of  their  mental  defect.  There 
is  not,  as  a  rule,  any  pronounced  sensory  disturbance,  although 
sometimes  hearing  is  impaired.  The  amentia  varies  from  a  mild 
degree  of  imbecihty  to  gross  inarticulate  idiocy.  If  paralysis  is 
present,  it  is  generally  a  paraplegia,  and  the  arms  are  rarely 
involved  in  these  cases  which  date  from  birth.  The  affected  legs 
are  small,  short,  ill-nourished,  and  their  muscles  exceedingly 
ill-developed.  They  may  be  strongly  adducted,  and  at  times 
quite  crossed  in  a  sartorial  posture.  Contractures  are  often 
present,  and  the  reflexes  are  usually  much  exaggerated.  In  some 
cases  the  paralysis  is  slight,  and  consists  simply  of  weakness  and 
dragging  of  the  limbs,  with  some  rigidity  and  increased  reflexes. 
Exceptionally  it  is  absent  altogether. 


Secondary  Amentia  and  its  Clinical  Varieties  209 

In  those  cases  which  arise  during  the  first  few  years  of  hfe,  either 
in  the  course  of,  or  as  a  sequel  to,  one  of  the  specific  fevers,  or 
as  a  cerebral  inflammation  apart  from  any  previous  illness,  the 
symptoms  are  slightly  different.  The  first  indications  of  an  affec- 
tion of  the  brain  are  often  malaise  and  vomiting,  and  these  are  fol- 
lowed by  restless  delirium  or  unconsciousness,  fever,  convulsions, 
and  often  paralysis.  The  fact  that  the  onset  of  many  of  these  cases 
is  so  often  attended  with  convulsions  causes  them  to  be  frequently 
designated  "epileptic"  or  "eclampsic"  amentia,  whereas  the 
convulsions  are  in  reality  a  symptom  and  not  a  cause.  They  are 
: :,  sometimes  very  severe,  and  may  recur  with  great  frequency  for 
several  days.  The  temperature  rarely  rises  to  more  than  102°  F. 
Paralysis  may  be  noticed  at  the  onset,  or  it  may  not  appear  until 
a  few  days  afterwards.  It  may  even  be  absent  entirely.  When 
present  it  usually  consists  of  monoplegia  or  hemiplegia  ;  diplegia 
is  rare.  The  reflexes  are  increased,  but  there  is  rarely  any 
marked  disturbance  of  sensation.  In  course  of  time  the  fever 
abates,  the  convulsions  cease,  or  continue  only  at  rare  intervals, 
the  child  recovers  consciousness,  and  some  amount  of  improve- 
ment takes  place  in  the  paralysis.  But  the  psychic  functions 
have  been  damaged  ;  in  some  cases  an  obvious  impairment  of  the 
intellect  is  noticed  immediately,  in  others  only  as  the  child  begins 
to  get  about  and  mix  with  his  companions.  If  he  had  begun  to 
speak,  he  may  be  now  speechless.  The  playmates  and  games  of 
which  he  was  formerly  fond  now  cease  to  attract  him.  His  whole 
behaviour  and  disposition  jnay  be  so  altered  that  the  parents 
remark  upon  the  change.  As  time  passes,  it  is  found  that  his 
capacity  for  learning  has  been  interfered  with,  and  it  is  soon 
evident  that  the  illness  has  resulted  in  a  more  or  less  serious 
arrest  of  mental  development. 

In  view  of  the  widely  differing  ultimate  effects  of  these  cerebral 
lesions,  it  is  obvious  that  no  accurate  forecast  is  possible.  Of  the 
children  born  with  asphyxia,  the  number  in  whom  amentia  results 
is  exceedingly  small,  and  careful  observation  of  the  child  for  a  few 
days  will  usually  enable  the  physician  to  reassure  the  parents  on 
this  head.  Of  the  cases  happening  during  early  childhood,  the  pro- 
portion who  become  aments  is  much  larger,  and  this  possibility  can 
never  with  certainty  be  excluded  until  the  lapse  of  some  time  after 
the  illness.     If  paraplegia  be  present  (which,  however,  is  relatively 

14 


2IO  Pvlental  Deficiency 

rare),  then  it  is  highly  probable  that  some  degree  of  mental 
deficiency  will  result.  Apart  from  this,  however,  the  degree  of 
paralysis  affords  no  indication  as  to  the  amount  of  psychic  damage. 
There  may  be  extensive  hemiplegia  with  no  intellectual  defect, 
or  there  may  be  profound  amentia  with  but  trifling  or  even  no 
paralysis  at  all.  Even  were  one  able  to  exclude  all  involvement 
of  the  psychic  areas,  there  would  still  be  the  possibility  of  recurrent 
epilepsy,  and  the  consequent  induction  of  amentia  and  dementia. 

The  mental  deficiency  in  these  cases  may  be  slight  or  severe. 
Some  patients  are  merely  feeble-minded,  and  beyond  a  general 
simplicity  and  childishness,  an  inability  to  get  on  at  school  and  to 
fend  for  themselves,  they  are  capable  of  a  considerable  amount 
of  useful  work  under  supervision.  Others  belong  to  the  imbecile 
grade,  and  are  capable  of  very  little  ;  others  are  idiots.  In  some 
persons  the  defect  seems  to  be  more  particularly  marked  in  certain 
faculties  ;  thus,  we  find  that  in  some  the  memory  is  chiefly 
affected,  in  others  the  attention  or  the  power  of  speech.  In  dis- 
position and  behaviour  some  of  these  aments  are  placid,  contented, 
affectionate,  and  trustworthy,  but  others  are  very  emotional  and 
undependable.  I  am  inchned  to  think  that  a  suspicious  dispo- 
sition and  general  irritability  of  temper,  together  with  a  liability 
to  be  easily  upset  and  to  commit  impulsive  actions,  are  very 
common  characteristics  of  patients  suffering  from  this  variety  of 
amentia.  As  already  remarked,  there  are  no  stigmata  of 
degeneracy,  and  in  the  majority  of  these  persons  the  bodil}^ 
development  and  nutrition  are  normal.  Often,  indeed,  as 
Langdon  Down  said,  they  are  of  winsome  and  comely  appearance. 

It  is  impossible  to  formulate  more  than  very  general  rules 
as  to  the  prospects  of  improvement  in  these  cases.  On  the 
whole,  if  the  case  is  really  a  secondary  one,  and  not  a  case 
of  primary  amentia  complicated  by  a  gross  cerebral  lesion,  and 
if  convulsions  are  not  frequent,  there  is  a  likelihood  of  a  fair 
amount  of  improvement  under  proper  educational  methods. 
But  such  training  must  be  begun  early  to  be  of  much  avail,  and, 
unfortunately,  one  finds  a  very  great  tendency  to  postpone  it 
until  too  late,  under  a  mistaken  trust  that  the  child  will  "  grow 
out  of  it."  The  extent  of  paralysis  is  no  criterion  as  to  the 
possibility  of  improvement.  Some  of  the  most  hopeless  cases  are 
those  in  whom  there  is  no  paralysis,  whilst  some  of  those  who 


Secondary  Amentia  and  its  Clinical  Varieties  2 1 1 

suffer  from  a  severe  physical  handicap  may  be  taught  to  perform 
really  useful  work.  Recurring  convulsions  are  of  much  more 
unfavourable  import. 

Paralytic  Aments. — In  a  large  proportion  of  these  cases  paralysis 
is  present,  and  such  are  often  described  as  paralytic  aments. 
But  the  association  is  not  invariable,  and  it  is  more  correct  to 
look  upon  the  paralysis  as  a  symptom  or  compHcation,  albeit  a 
frequent  one.  The  amount  of  paralysis  varies  enormously, 
ranging  from  a  partial  monoplegia  to  a  hemi-  or  (rarely)  para- 
plegia. In  some  cases  the  only  observable  defect  may  be  a 
want  of  opposition  of  the  thumb  of  one  side.  In  others  there  is  a 
severe  hemiplegia,  accompanied,  it  may  be,  by  some  weakness 
of  the  opposite  foot.  In  the  traumatic  or  asphyxial  cases,  double 
talipes  equino-varus  is  not  uncommon  ;  both  legs  may  be  com- 
pletely paralyzed,  and  occasionally  spastic  paresis  of  the  legs  may 
be  accompanied  by  an  inability  to  perform  certain  fine  move- 
ments of  the  hands.  As  a  rule,  the  face  and  tongue  are  not 
involved.  The  muscles  affected  are  those  concerned  in  the 
performance  of  definite  movements,  and  they  usually  become 
considerably  atrophied  ;  but  there  is  no  reaction  of  degeneration. 
In  course  of  time  rigidity  and  shortening  take  place,  with  the 
development  of  contractures  and  abnormal  postures.  The 
reflexes  are  usually  exaggerated,  and  Babinsky's  toe  sign  is 
frequently  present.  In  fact,  the  grouping  and  general  features 
of  the  paralysis  are  characteristic  of  a  lesion  of  the  upper  efferent 
pathway.  In  some  cases,  however,  I  am  inclined  to  think  it  may 
descend  so  as  to  involve  the  lower  spinal  tract. 

In  other  cases  convulsions  are  a  prominent  feature,  and  these 
may  occur  with  or  without  paralysis.  As  a  rule,  in  their  onset, 
course,  and  post-convulsive  state  these  are  indistinguishable 
from  those  of  ordinary  idiopathic  epilepsy  ;  but  in  some  cases 
they  are  of  a  Jacksonian  character.  In  one  of  my  patients  both 
localized  and  general  convulsions  occurred,  the  former  un- 
attended by  loss  of  consciousness  ;  but  they  gradually  passed  into 
the  typically  epileptic  variety,  and  I  think  this  is  the  tendency  in 
most  of  these  cases  where  the  fits  begin  as  Jacksonian.  Some- 
times paralysis  may  exist  for  years  without  any  fits,  and  then 
epilepsy  suddenly  makes  its  appearance.  Petit  mal  also  occurs. 
In  a  few  cases  there  is  seen  a  constant  rhythmic  tremor  or 

14 — 2 


212  Mental  Deficiency 

irregular  choreiform  movements  without  epilepsy.  As  already 
mentioned,  those  cases  the  origin  of  which  is  marked  by  a  series 
of  convulsions  are  often  described  as  eclampsic  amentia,  whilst 
those  in  which  the  fits  continue,  and  have  the  characters  of 
epilepsy,  are  spoken  of  as  epileptic  amentia.  In  my  opinion, 
however,  this  latter  term  should  be  restricted  to  cases  of  *amentia 
due  to  idiopathic  epilepsy  without  a  gross  lesion. 


Illustrative  Cases. 

Medium-Grade  Amentia,  with  Hemiplegia  and  Convulsions,  the 
Result  of  a  Birth  Injury. — M.  B.,  female.  No  family  history 
obtainable.  The  j)atient  has  had  fits  and  paralysis  since  a  baby, 
supposed  to  be  dne  to  ^n  i'r^jy;Q/  a-|  birth.  She  went  to  school  for 
aTtew  yeais,  but  could  never  learn.  At  twelve  years  of  age  was 
admitted  into  workhouse  in  consequence  of  death  of  parents. 
Was  thence  sent  into  the  asylum  owing  to  epileptic  fits.  She  is  now 
twenty-two  years  of  age,  and  has  been  under  my  observation  for 
two  years.  She  is  a  placid,  simple -looking  girl  of  apparently 
seventeen  years  or  so,  rather  small,  but  well-nourished,  and 
devoid  of  stigmata  of  degeneracy.  There  is  left  hemiplegia 
involving  the  leg,  arm,  hand,  and  lower  part  of  the  face.  The 
reflexes  are  exaggerated  on  both  sides,  and  there  is  slight  lateral 
nystagmus.  No  impairment  of  sensation  can  be  made  out. 
She  is  subject  to  convulsive  attacks  without  loss  of  consciousness, 
the  duration  of  which  has  been  as  long  as  two  hours.  These 
consist  of  clonic  movements  of  the  left  (paralyzed)  hand  and 
arm,  with  twitching  of  the  left  corner  of  the  mouth,  and  drawing 
of  the  head  to  the  left  side.  During  the  attack  the  knee-jerks 
are  exaggerated  (particularly  the  left),  but  there  is  no  ankle  clonus, 
and  the  pupils  are  normal.  She  says  that  the  attacks  are  pre- 
ceded by  a  "  feehng  "  under  the  left  arm,  and  that  whilst  they 
last  she  feels  pins  and  needles  in  the  left  face,  arm,  and  leg. 
Some  of  these  attacks  are  followed  by  a  state  of  general  rigidity, 
with  loss  of  consciousness.  In  addition  she  has  petit  mal  and 
convulsions  which  are  typically  epileptic.  Her  mental  con- 
dition is  that  of  a  high-grade  imbecile.  She  can  carry  on  a 
simple  conversation,  but  does  not  volunteer  information,  and  she 
will  agree  to  almost  anything  suggested  to  her.    She  cannot  read, 


Secondary  Amentia  and  its  Clinical  Varieties  213 

but  can  just  scrawl  her  name.  She  can  count  up  to  thirty,  but 
cannot  say  what  two  and  two  make.  She  will  do  what  she  is  told, 
and  helps  in  the  ward-cleaning.  Her  memory  is  poor  ;  she  has  no 
idea  of  time  or  dates,  but  her  attention  is  tolerably  good.  She 
is  occasionally  mischievous  and  takes  things  from  the  other 
patients,  but  on  the  whole  is  well-behaved  and  gives  little 
trouble. 

Amentia  with  Double  Talipes  due  to  Asphyxia  Neonatorum. — 
M.  F.,  female.  There  is  nothing  abnormal  in  the  family  history . 
The  patient  is  the  fifth  of  a  family  of  ten  ;  two  died  in  infancy, 
the  remainder  are  healthy.  The  mother  tells  me  that  M.  F. 
was  a  very  large  child,  that  the  labour  was  very  prolonged,  and 
that  she  was  so  blue  and  Hfeless  at  birth  that  the  doctor  in 
attendance  had  to  make  ''  an  opening  in  her  throat."  I  do  not 
know  what  this  could  have  been,  and  can  find  no  evidence  (at 
seventeen  years  of  age)  of  any  tracheotomy  scar  ;  but  there 
seems  little  doubt  that  the  child  had  severe  asphyxia  neona- 
torum. The  mother  sa57s  she  was  quite  "  dummy  "  from  birth, 
and  utterly  different  to  the  other  children  ;  that  she  had  severe 
fits  whilst  cutting  her  teeth,  did  not  walk  until  four  and  a  half 
years,  and  never  said  a  word  until  she  was  in  her  sixth  year.  She 
went  to  school,  but  could  not  learn,  and  she  afterwards  had 
several  situations,  but  could  not  keep  them,  as  she  seemed  too 
simple  and  childish.  At  the  age  of  seventeen  years  she  began  to 
get  very  troublesome  and  spiteful ;  she  was  considered  a  danger 
to  the  younger  children,  and  sent  to  the  asylum. 

Upon  admission  she  was  a  fairly  well-grown  girl,  with  a  de- 
cidedly childish  and  vacuous  expression.  There  was  no  observable 
sensory  defect.  She  could  understand  what  was  said  to  her,  and 
was  capable  of  replying  to  simple  questions.  She  could  read  and 
write  words  of  one  syllable,  and  could  add  up  to  ten.  On  the 
whole  she  was  quiet  and  well-behaved,  and  did  a  certain  amount 
of  work  in  the  laundry  under  supervision  ;  but  she  had  no  power 
of  reasoning,  and  was  obviously  far  too  deficient  to  earn  her 
living.  She  was  of  a  remarkably  facile  disposition,  and  readily 
assented  to  an}^  proposition  made  to  her ;  she  also  had  a  consider- 
able defect  in  the  power  of  sustained  attention.  Speech  was 
exceedingly  indistinct.  She  had  double  talipes  varus,  with  some 
dragging  of  the  feet  in  walking,  but  no  other  signs  of  paresis.  She 


214  Mental  Deficiency 

is  now  nineteen  years  of  age.  She  has  had  no  fits  since  childhood, 
but  her  mental  deficiency  is  becoming  more  marked.  She  is  at 
times  rambling  and  incoherent  in  her  conversation,  but  is  on  the 
whole  well-behaved  and  gives  no  trouble.  The  slight  paresis  of 
the  feet  is  somewhat  more  pronounced  than  formerly,  and  tlie 
knee-jerks  are  exaggerated. 

Amentiadue  to  Traumatic  Epilepsy. — 5.  V. ,  female.  The  patient 
is  the  sixth  ol  a  lamiiy  ol  tefTTtwo  sisters  died  in  infancy,  but  the 
remainder  are  well  grown  and  quite  healthy  in  body  and  mind. 
A  complete  family  history  was  obtained,  and  revealed  an  entire 
absence  of  morbid  heredity. 

S.  V.  was  born  at  full  term  without  any  abnormal  circum- 
stances. She  cut  her  teeth,  walked,  and  talked  at  the  ordinary 
age,  and,  in  fact,  appeared  to  be  a  perfectly  healthy  child  until 
four  years  of  age.  She  then  had  a  fall  in  the  street,  striking  her 
head  against  the  curb  ;  she  remained  unconscious  for  half  an 
hour,  and  then  came  to,  but  seemed  dazed.  Five  weeks  after- 
wards she  had  her  first  epileptic  fit,  and  they  have  continued 
almost  daily  since. 

I  saw  this  girl  for  the  first  time  at  the  age  of  fourteen  years. 
She  was  tolerably  well  grown  for  her  age,  and  had  no  stigmata  of 
degeneracy,  although  quite  idiotic  in  manner  and  facies.  She 
did  not  understand  all  that  was  said  to  her,  but  could  obey  some 
commands  by  signs.  She  was  incapable  of  any  kind  of  work,  and 
could  not  dress  or  feed  without  help.  Constantly  wet  and  dirty. 
Could  say  a  few  monosyllabic  words,  but  most  of  her  utterances 
were  inarticulate  grunts.  She  was  said  to  be  good-tempered  and 
quite  harmless.  On  careful  examination,  I  found  that  there 
was  slight  dragging  with  e version  of  the  right  foot.  The  right 
face  was  also  less  full  than  the  left,  but  there  were  no  other 
locaHzing  symptoms.  The  fits  were  typically  epileptic,  and 
followed  by  a  prolonged  period  of  unconsciousness.  I  came  to 
the  conclusion  that  the  case  was  probably  one  of  combined 
amentia  and  dementia,  the  result  of  traumatic  epilepsy,  and 
although  I  thought  it  very  douBTfuTwKether  anything  could  be 
done  so  long  after  the  injury,  I  recommended  operation  as  a 
justifiable  and  the  only  possible  measure. 

Mild  Amentia,  with  Paralysis  and  Convulsions,  consequent  upon 
."  Infantile  Hemiplegia." — F.  D.  W.,  male.     No  morbid  heredity. 


Plate  XVI. 


■>  c 
.2 

HI 


u 


To  /ace  page  214] 


■-'.-^t 


Secondary  Amentia  and  its  Clinical  Varieties  215 

His  brothers  and  sisters  are  healthy  in  body  and  mind,  and  the 
patient  appeared  perfectly  normal  until  his  second  year.  He 
then  had  a  severe  illness,  which  left  him  paralyzed  in  the  right 
hand  and  arm,  and  a  few  years  later  he  was  noticed  to  be  more 
simple  than  other  children  of  his  age.  He  went  to  school,  but 
could  never  get  on,  and  he  cannot  read,  write,  or  sum.  Upon 
leaving  school  he  used  to  help  his  father  (who  is  a  publican)  in  the 
bar,  but  he  has  never  followed  any  regular  employment.  He  was 
subject  to  occasional  epileptic  fits,  and  after  one  of  these 
assaulted  his  father  and  sister,  and  became  so  unmanageable 
generally  that  he  had  to  be  sent  to  an  asylum,  where  he  has  since 
remained. 

He  is  now  forty-two  years  of  age,  and  is  a  well-developed  man  of 
medium  height,  with  no  stigmata  of  degeneracy.  His  facial  ex- 
pression is  placid  and  somewhat  childish.  There  is  dropping  of 
the  right  wTist,  and  the  interossei  as  well  as  the  muscles  of  the 
thenar  and  hypothenar  eminences  and  forearm  are  very  httle 
developed.  The  whole  of  the  right  forearm  is  short  and  stunted, 
as  compared  with  the  left.  He  can  make  use  of  the  affected  arm 
for  coarse  purposes,  but  he  cannot  perform  fine  movements.  He 
cannot  move  the  toes  of  the  right  foot,  and  they  are  cold  and  blue, 
but  there  is  no  other  observable  paralysis  of  this  or  any  other 
portion  of  the  body.  There  is  no  sensory  defect,  and  he  has  had  no 
fits  for  several  years. 

His  memory  is  only  fair,  and  is  better  for  remote  than  recent 
events.  His  power  of  attention  is  good,  and  he  has  no  special 
sense  defect.  He  can  carry  on  a  simple  conversation,  and  can 
give  a  tolerably  good  account  of  his  past  life  ;  but  his  general 
intelHgence  is  poor,  and  he  is  too  childish  to  take  care  of  himself 
without  supervision.  He  is  very  suspicious  of  strangers,  and  very 
disinclined  to  answer  their  questions.  He  is  emotional,  and 
readily  moved  to  laughter  or  tears.  He  is  very  variable  in 
temper,  and  at  times  surly,  perverse,  and  very  troublesome,  but 
at  others  he  is  a  not  unwilling  worker  in  the  dormitories.  (See 
Plate  XVL,  Fig.  41.) 

Mild  Amentia  with  Paraplegia,  due  to  a  Cerebral  Lesion  during 
Birth. — T.  W.,  male,  aged  thirty-three  years.  Owing  to  the 
death  of  the  patient's  parents  a  complete  history  is  unobtainable, 
butj  as  far  as  can  be  ascertained,  there  is  no  morbid  heredity,  and 


2i6  Mental  Deficiency 

the  condition  is  the  result  of  a  lesion  during  birth,  which  left 
the  patient  paralyzed  in  both  legs  and  mentally  defective.  He 
has  been  in  institutions  since  childhood,  and  although  he  has 
learned  to  read  and  write  fairly  well,  and  even  to  do  simple  sums 
in  arithmetic,  the  absence  of  any  systematic  manual  training, 
together  with  his  general  intractability,  cause  him  to  be  quite 
unemployed. 

He  has  an  alert,  and  at  times  a  decidedly  cunning,  look,  and  his 
features  are  of  a  low  animal  type,  but  there  are  no  obvious  stigmata 
of  degeneracy.  The  skull  is  symmetrical  and  larger  than  usual,  the 
circumference  being  23  inches.  Both  lower  limbs  are  completely 
paralyzed  from  the  thighs  downwards  ;  they  are  also  very  small 
and  imperfectly  developed,  blue  and  cold,  and  covered  with  a 
plentiful  growth  of  hair.  Tactile  sensation  is  markedly  dimin- 
ished in  the  paralyzed  limbs,  and  the  knee-jerks  and  plantar 
reflexes  are  absent.  Walking  is  impossible,  but  the  patient  is 
very  adept  at  propelling  himself  along  his  haunches  by  making 
use  of  his  hands  and  arms  as  levers.  There  have  never  been  any 
convulsions. 

There  is  no  defect  of  the  special  senses .  He  understands  most  of 
what  is  said  to  him,  and  can  reply,  but  usually  refuses  to  do  so. 
His  memory  is  good  ;  he  is  very  observant,  and  capable  of  simple 
reasoning  ;  but  he  cannot  follow  an  argument,  and  his  ideas  and 
general  behaviour  are  characterized  by  a  childish  simplicity. 
The  powers  of  attention  and  control  are  markedly  defective.  If 
asked  to  write  his  name,  he  takes  the  pencil  in  his  hand,  looks  at  it, 
and  then  puts  it  down  to  look  at  his  arm.  He  then  takes  it  up 
again  and  makes  a  start,  but  drops  it  to  scratch  his  back. 
Another  beginning  is  interrupted  to  look  at  some  one  coming  in 
at  the  door.  In  fact,  he  is  as  inquisitive  and  curious  as  a  monkey, 
and  so  distracted  by  everything  happening  around  him  that  he 
can  settle  down  to  nothing.  He  is  destructive  and  constantly 
tears  up  his  clothes,  and  from  time  to  time  he  has  outbreaks  of 
noisy  violence,  during  which  he  uses  disgusting  language  and 
attacks  anyone  who  may  be  near  him.     (See  Plate  XVI.,  Fig.  42.) 

Amentia  with  Epilepsy,  due  to  "  Sunstroke.'' — E.  S.,  male.  The 
eighth  born  of  a  family  of  nine,  all  the  others  being  healthy. 
There  is  a  tendency  to  alcoholism  on  the  parental  side,  but  no 
insanity,  epilepsy,  or  consumption.     The  patient  seemed  per- 


Secondary  Amentia  and  its  Clinical  Varieties  217 

fectly  well  until  three  years  of  age.  Dentition  had  been  normal ; 
he  was  able  to  walk  well,  and  was  making  progress  with  his  talk- 
ing. When  just  turned  three  he  had  "what  the  doctor  called 
raeningitis  "  following  exposure  to  a  severe  sun.  The  mother  says 
that  for  nine  weeks  he  was  unconscious  and  repeatedly  convulsed. 
For  twelve  months  after  this  he  never  uttered  a  syllable  ;  he 
then  began  to  pick  up  a  few  words  again,  but  made  little  progress, 
and  his  parents  noticed  a  profound  change  in  him.  Usually 
he  was  dull  and  stupid,  and  seemed  to  have  little  sense,  but  at 
times  he  became  violent  and  unmanageable ;  the  fits  continued 
at  short  intervals.  At  the  age  of  nine  he  became  so  trouble- 
some that  he  had  to  be  sent  to  the  asylum.  On  admission  he  was 
somewhat  undersized  for  his  age,  and  poorly  nourished.  His 
features  were  good,  and  there  were  no  stigmata  of  degeneracy,  but 
the  expression  was  vacant.  Fits  occurred  daily  ;  they  were  very 
severe,  preceded  by  cry,  followed  by  a  period  of  unconscious- 
ness, and  had  all  the  characteristics  of  true  epilepsy.  He  could 
understand  what  was  said  to  him,  and  would  occasionally  reply, 
but  as  a  rule  he  was  moody  and  silent  and  resented  being  ques- 
tioned. He  was  incapable  of  any  employment.  The  patient 
steadily  became  worse.  He  was  a  confirmed  masturbator  and 
addicted  to  swallowing  pebbles.  He  became  wet  and  dirty, 
required  to  be  fed,  and  needed  constant  attention.  He  took  no 
notice  of  his  surroundings,  did  not  seem  to  understand  what  he 
was  told,  and  if  examined  became  very  resistant  and  forbidding. 
At  times  he  would  sit  in  a  chair  flapping  his  arms  and  making 
hideous  noises  ;  at  others  he  was  moodily  silent.  He  died  at  the 
age  of  seventeen  years,  of  exhaustion  after  a  series  of  fits. 

On  making  a  post-mortem  examination,  I  found  the  skull  very 
thick  and  dense,  the  diploe  being  obliterated.  The  brain  was 
small,  and  weighed  37J  ounces,  the  left  hemisphere  being 
—5^  ounces  less  in  weight  than  the  right.  The  ventricles  were 
dilated,  and  there  was  considerable  excess  of  clear  fluid.  The 
membranes  appeared  normal.  The  brain  was  tolerably  well  con- 
voluted, and  presented  nothing  abnormal  externally  beyond  a 
general  dimmution  01  size.  On  making  carelul  sections,  however, 
a  localized  area  of  softening,  about  the  size  of  a  filbert,  was  found 
in  the  left  supramarginal  convolution  at  the  junction  of  the  grey 
and  white  matters.     This   in   all  probabiHty  was   of  vascular 


21 8  Mental  Deficiency 

origin,  and  the  fina]jradt_of_Jh£_attac^^^^  encephaJitkjKfeich 
took  place  at  three  years  of  age.     (See  Plate  XVII.,  Fig.  43.) 

Mild  Amentia  with  Motor  Aphasia,  due  to  an  Infantile  Cerebral 
Lesion. — The  following  is  a  case  of  secondary  amentia  consequent 
upon  infantile  convulsions  (eclampsia)  ;  it  is  probable,  however, 
that  these  were  the  result  of  some  toxic  lesion  of  the  brain. 

A^.  T.,  male,  born  in  India,  the  second  child  of  a  family  of  six. 
Parents  healthy,  and  no  morbid  heredity.  Seemed  perfectly 
normal  until  nine  months  old,  when  he  had  a  series  of  convulsions 
lasting  three  days.  These  continued,  at  intervals  of  a  few  months, 
until  he  was  three  years  of  age  ;  they  were  attended  with  un- 
consciousness, and  in  the  last  attack  he  was  given  up  by  the 
doctor.  He  recovered,  however,  and  has  had  no  further  fits, 
but  from  that  time  his  parents  noticed  a  great  mental  change. 
He  failed  to  understand  what  was  said  to  him,  became  restless  at 
night,  exceedingly  dirty  in  his  habits,  and  required  constant 
watching  during  the  day  to  prevent  him  destroying  everything  he 
laid  his  hands  on.  As  time  passed  some  improvement  took  place  : 
he  became  more  manageable,  and  able  to  do  little  things  for  him- 
self. He  would  also  help  his  mother  in  laying  the  dinner-table  and 
similar  household  duties,  but  he  could  not  be  depended  upon, 
was  at  times  very  intractable,  and  was  quite  unable  to  speak. 

I  first  saw  him  at  the  age  of  eleven  years.  He  was  a  sturdy, 
well- developed  boy,  with  good  features  but  a  decidedly  vacuous 
expression.  There  was  no  sensory  defect  ;  he  could  understand 
simple  commands  and  remarks ;  but  he  was  obstinate,  and  took 
little  notice  of  anything  said  to  him.  He  could  whistle,  but  could 
not  articulate,  and  he  was  passionate  and  untrustworthy.  As  far 
as  could  be  ascertained  in  the  absence  of  conversation,  his  general 
intelhgence  was  about  equal  to  that  of  a  normal  child  of  five  or 
six  years.  I  came  to  the  conclusion  that  the  case  was  one  of 
mild  amentia  secondary  to  meningo -encephalitis  of  the  frontal 
lobes,  and  involvmg  the  motor  speechrci5TrtT^7and  c'olrisidered  the 
prospect  of  improvement  sHght,  but  recommended  special  training 
in  an  institution.  This  has  now  been  carried  out  for  three  years. 
He  has  improved  greatly  in  habits  and  general  behaviour,  he 
is  now  thoroughly  obedient  and  dependable,  and  evinces  an 
affectionate  disposition  towards  those  about  him.  He  is  fond  of 
manual  work,  and  can  perform  many  kindergarten  occupations, 


Plate  XVII. 


To /ace  page  218.] 


I 


Secondary  Amentia  and  its  Clinical  Varieties  219 

such  as  plaiting  and  bead-threading,  very  well.  He  lays  the  dinner- 
plates  with  a  marvellous  dexterity.  He  has  learned  to  make  pot- 
hooks and  hangers,  knows  some  of  his  letters,  and  can  count  up  to 
six.  But  he  finds  school  work  very  uncongenial,  and  cannot  settle 
down  to  it.  He  seems  incapable  of  making  any  mental  effort. 
He  understands  all  that  is  said  to  him,  but  still  remains  unable 
to  articulate,  and,  in  spite  of  persistent  attempts  to  teach  him,  the 
nearest  approach  to  a  word  he  can  utter  is  a  guttural  "  cuckoo." 
In  the  following  case  there  is  slight  morbid  heredity,  but  mental 
development  proceeded  normally  until  an  attack  of  'Ijneiuiigiiis.^ 
in  infancy.  The  degree  of  defect  is  mild,  but  it  is  accom.panied 
■^y  evidences  of  instability,  which  will  probably  culminate  in 
actuatinsanity  before  adolescence  is  passed. 

K.  G.,  male.  Was  born  in  India,  and  has  four  brothers  and 
sisters  alive  and  well.  His  mother  is  an  exceedingly  delicate, 
neurotic  woman,  his  father  strongly  addicted  to  alcohol ;  but 
there  is  no  history  of  epilepsy  or  insanity  on  either  side.  The 
patient  seemed  all  right  until  fifteen  months  old,  when  he  was 
laid  up  for  two  months  with  some  brain  illness,  accompanied  by 
fits,  which  is  described  as  "  meningitis."  From  this  time  he 
became  subject  to  fits  of  irritability,  and  showed  indications  of 
mental  defect.  He  went  to  school  at  the  age  of  seven,  and 
showed  a  considerable  taste  for  drawing  and  manual  work  ; 
but  he  was  never  able  to  make  progress  in  any  studies,  and 
seemed  incapable  of  mental  apphcation.  I  saw  him  in  consulta- 
tion at  the  age  of  eleven  ;  he  could  then  read  and  write  simple 
sentences,  and  was  capable  of  simple  addition  and  subtraction 
sums.  He  had  a  good  memory,  and  could  recount  a  few  his- 
torical and  geographical  facts,  but  his  manner  was  very  restless 
and  his  attention  very  fitful ;  he  was  quite  incapable  of  settUng 
down  to  school  work,  and  his  general  intelligence  and  power  of 
reasoning  were  no  greater  than  those  of  a  normal  child  of  six 
years.  Cranial  circumference,  2if  inches.  He  was  affectionately 
disposed  to  those  about  him,  but  of  a  very  undependable  temper. 
Was  addicted  to  hiding  up  trifling  objects  of  no  value,  and  had 
wandered  away  from  home  on  several  occasions.  At  times  he 
was  destructive,  and  would  tear  up  clothes,  toys,  and  picture- 
books  indiscriminately.  Occasionally  he  was  noisy  and  aggres- 
sive, and  had  attacked  those  about  him. 


220  Mental  Deficiency 

Amentia  accompanied  by  Porencephaly  or  Cerebral 
Hemiatrophy. 

As  seen  in  the  post-mortem  room,  these  cases  appear  to  be 
widely  different  from  those  just  described,  in  which  the  patho- 
logical findings  are  cysts,  localized  atrophies,  softening,  meningo- 
encephalitis, and  the  like.  Here  we  have  to  do  with  a  condition 
of  porencephaly  or  hemiatrophy  of  such  an  extent  that  the 
affected  hemisphere  jnayjje^oo  or  300,  or  even  more,  grammes 
■^jgss"lnweight  than  the  opposite"^o!iepand  it  wmitd""see5__as  if 
such  must  be  accompanied  by  speciafclmical  features .  In  some 
instances  this  is  so,  and  on  that  account  it  is  desirable  to  refer  to 
these  conditions  separately.  But,  on  the  other  hand,  it  must  be 
admitted  that  these  severe  conditions  can  often  only  be  suspected 
during  life,  and  that  they  are  by  no  means  rarely  found  after 
death  when  there  had  previously  been  nothing  to  suggest  that 
more  than  a  minor  pathological  disturbance  was  present.  An 
interesting  case  of  this  nature  has  been  recorded  by  Conolly 
Norman  and  Fraser.*  It  was  that  of  a  very  fine  female  who  had 
never  been  under  restraint,  and  who  presented  no  external 
evidence  of  extensive  brain  disease  in  the  shape  of  atrophy,  con- 
tractures, etc.,  and  yet  post-mortem  there  was  found  extreme 
wasting  of  one  hemisphere,  as  well  as  of  the  corresponding  basal 
gangUa.  Many  similar  cases  in  which  the  clinical  signs  have 
been  comparatively  slight  have  been  recorded  by  other  writers- 
viz..  Van  der  Kolk,  Bianchi,  Heschl,  Spiller,  Lambl,  etc. 

In  most  cases  these  conditions  are  the  result  of  disease,  and] 
date  from  very  early  infancy,  if  not  from  uterine  existence  ;  a  few, 
however,  seem  to  be  due  to  primary  anomalies  of  development. 
But  the  distinction  can  only  be  inferred  cUnically,  and  not  always 
with  certainty  upon  dissection. 

During  life  an  ament  may  be  suspected  to  be  the  subject  ol 
porencephaly  or  extensive  hemiatrophy  if  there  is  severe  hemi- 
plegia accompanied  by  contractures  and  marked  non-develop^ 
ment  of  the  affected  limbs,  and  if  convulsions  are  also  present. 
Butj^aiS-^]xea,dy_Tem3iYked,  the  hemiplegia  is  often  astonishingly 
iiisjgnificant»--and  iFSfetv"jn^lve&  the  lutigiie  oil  face.     Th 

*  Conolly  Norman  and  Alec  Fraser,  "  A  Case  of  Porencephaly,"  Journc 
of  Mental  Science,  October,  1894. 


Secondary  Amentia  and  its  Clinical  Varieties  221 

convulsions  are  of  the  usual  epileptic  type,  and  are  fairly  frequent, 
-brrTcases  have  been  recorded  in  which  they  were  absent.  Some- 
times much  headache  is  complained  of.  The  diagnosis  is  rendered 
more  probable  if,  in  addition,  there  is  marked  flattening  of  one 
side  of  the  skull,  but  in  many  of  these  cases  the  space  is  filled  up  by 
excessraf~^trrdn5r^owth  of -the  tnner  table  only.  I  know  of  no 
othet distinguishing  features.  The  amentia  may  be  of  any  grade, 
from  a  mild  imbecility  to  gross  idiocy,  and'stigmata  of  degeneracy 
nmyl3e  preset  or  absent  according  as  the  case  is  one  of  primary 
amentia  comphcated  by  these  lesions,  or  one  of  secondary 
amentia  due  to  them.  In  the  latter  dementia  often  supervenes,  and 
death  frequently  results  from  tuberculosis  or  follows  a  succession 
of  fits.  Of  Kundrat's*  series  of  eighteen  cas$§"'^f^orencephaly, 
only  three  survived  the  period  of  infancy. 

Illustrative  Cases. 

False  Porencephaly  with  Cystic  Formation. — A.  E.  IF.,! female. 
Imbecile.  No  morbid  heredity.  Born  paralyzed  on  right  side. 
Constantly  suffered  from  headache  and  epileptic  fits.  The 
paralysis  involved  the  right  arm  and  leg,  but  not  the  face.  The 
affected  limbs  were  smaller  and  shorter  than  the  sound  ones. 
There  was  taUpes  equino-varus  of  the  right  foot,  but  no  contrac- 
tures. The  knee-jerks  were  absent.  Speech  indistinct,  memory 
poor,  depressed  and  dull  mentally.  She  was  subject  to  frequent 
fits,  beginning  in  the  affected  side,  and  then  becoming  general. 
She  gradually  became  more  and  more  demented,  and  died  at  the 
age  of  twenty-two,  after  a  succession  of  severe  fits. 

The  post-mortem  examination  showed  extensive  atrophy  of 
the  lower  part  of  the  motor  region  on  the  left  side,  and  of  the 
corresponding  efferent  tract  in  the  pons,  meduUa,  and  cord. 
The  depression  in  the  brain  was  occupied  by  a  subarachnoid 
cyst.  The  left  ventricle  also  was  greatly  dilated.  The  weight 
of  the  left  hemisphere  was  435  grammes,  and  of  the  right 
585  grammes. 

Cerebral  Hemiatrophy  with  Ventricular  Dilatation. — /.  E.,  male. 

*  Op  cit. 

f  For  a  fuller  description  of  the  histological  appearances  in  this  and  the 
following  case,  see  "  Hemiatrophy  of  the  Brain,"  by  Mott  and  Tredgold, 
Brain,  part  xc,  1900. 


222  Mental  Deficiency 

Fits,  paresis  of  right  arm,  and  weak-mindedness  from  infancy. 
The  right  leg  also  weak,  but  he  was  able  to  walk,  and  he  had 
been  engaged  as  a  shoeblack.  He  was  admitted  into  the  asylum 
at  the  age  of  twenty-six  in  consequence  of  frequent  epileptic  fits 
accompanied  by  attacks  of  noisy  excitement.  On  several 
occasions  he  had  attacked  those  about  him  without  provoca- 
tion. He  gradually  became  demented,  and  died,  aged  thirty,  of 
acute  phthisis. 

On  post-mortem  examination  the  skull  was  symmetrical 
externally,  but  there  was  marked  thickening  of  the  whole  of  the 
inner  table 'ohThe  left  side.  In  some  sittrnthrrrrTtiethickness 
was  more  than  twice  that  of  the  opposite  side.  The  weightf^f 
the  right  hemisphere  was  575  grammes,  that  of  the  left  but 
155  grammes.  The  left  ventricle  was  hugely  dilated,  the  sub- 
stance of  the  hemisphere  being  reduced  to  a  mere  shell  in  places. 
The  left  basal  ganglia,  particularly  the  optic  thalamus,  were  also 
exceedingly  small  and  ill-developed.  There  was  consecutive 
atrophy  of  the  left  crus,  pyramid  and  fillet  in  the  pons  and 
medulla,  with  atrophy  of  the  right  half  of  the  cerebellum  and  its 
superior  peduncle.  There  was  also  sclerosis  of  the  left  direct 
and  right  crossed  pyramidal  tracts  in  the  cord,  of  the  left  antero- 
lateral column,  and  marked  numerical  diminution  of  the  anterior 
horn  cells  in  the  cervical  and  lumbar  regions. 

The  following  description,  by  Dr.  Ross,  of  a  case  of  double 
true  'porencephaly  (which  is  exceedingly  rare)  is  quoted  by  Ireland  : 

"  The  patient  was  a  little  girl  who  died  of  croup  at  the  age  of 
two  years  and  five  months.  At  the  age  of  three  months  her 
parents  first  observed  that  she  could  not  hold  her  head  up,  and 
that  her  hands  were  stiff.  She  never  at  any  time  suffered  from 
convulsions.  The  child  was  small  for  her  age,  but  fairly 
nourished.  The  legs  were  kept  in  a  half -flexed  condition,  the 
feet  extended,  and  the  heels  drawn  up.  The  arms  were  held 
semi-flexed  in  a  symmetrical  position.  The  muscles  of  both 
extremities  were  in  a  state  of  spasmodic  rigidity.  Any  attempt 
to  alter  by  passive  motion  the  position  of  the  limbs  caused 
increased  spasmodic  contractions.  The  head  was  kept  bent 
forwards,  the  chin  upon  the  sternum  ;  but  she  could  raise  her 
head  by  an  effort,  soon  again  to  fall  into  the  old  posture.  She 
could  voluntarily  grasp  an  object  with  each  hand,  but  the  move- 


■     Secondary  Amentia  and  its  Clinical  Varieties  223 

ments  were  irregular  and  uncertain.  She  could  only  utter  a  few 
monosyllables." 

"  On  examination  after  death  a  deep  sulcus  was  found  in  each 
side  of  the  brain,  about  the  site  of  the  fissure  of  Rolando,  extend- 
ing from  the  point  of  bifurcation  of  the  Sylvian  fissure  for  about 
ij  inches  upwards.  Each  sulcus  opened  into  the  corresponding 
lateral  ventricle  by  an  aperture  the  size  of  the  little  finger.  Each 
opening  was  surrounded  by  a  ring  of  grey  matter  having  all  the 
naked  eye  appearances  of  the  cortex.  The  ascending  frontal  and 
ascending  parietal  appeared  to  be  absent,  and  the  surrounding 
gyri  were  displaced.  The  crura  cerebri,  pons  and  medulla 
appeared  quite  normal  to  the  naked  eye."  Microscopical 
examination  showed  that  the  cortex  contained  a  number  of 
imperfectly  developed  cells  almost  destitute  of  processes.  The 
anterior  pyramids  of  the  medulla  also  were  not  more  than  half 
the  size  of  those  of  a  normal  child  of  corresponding  age,  and  the 
lateral  columns  of  the  cord  were  also  diminished  in  size. 

Bourneville*  has  recorded  six  cases  of  cerebral  hemiatrophy, 
of  which  the  following  are  synopses.  All  the  patients  were 
imbeciles  or  idiots,  and  almost  all  suffered  from  epileptic  con- 
vulsions, and  showed  post-mortem  sclerosis,  atrophy,  and  chronic 
^"^^ebaftges  in  the  membranes  and  brain  tissue. 

1.  Pseudo -porencephaly.  Fifteen  years  old.  Left  hemiplegia 
with  epilepsy.  Right  hemisphere,  240  grammes.  Left  hemi- 
sphere, 560  grammes. 

2.  Imbecile.  Twenty-one  years.  Right  hemiplegia  and 
epilepsy.  Right  hemisphere,  465  grammes.  Left  hemisphere, 
185  grammes. 

3.  Imbecile.  Eleven  years.  Left  hemiplegia  and  epilepsy. 
Left  hemisphere,  570  grammes.  Right  hemisphere,  310  grammes, 
showing  pachymeningitis  and  meningo-encephahtis. 

4.  Idiot.  Four  and  a  half  years.  Right  hemisphere, 
460  grammes.  Left  hemisphere,  200  grammes,  with  marked 
sclerosis. 

5.  Imbecile.    Thirteen  years.    Right  hemiplegia.    Right  hemi- 
'  sphere,  665  grammes.     Left  hemisphere,  455  grammes. 

6.  Idiot.  Ten  years.  Right  hemisphere,  477  grammes.  Left 
hemisphere,  255  grammes. 

.    *  Bourneville,  Progr^s  Medical,  1898,  p.  248. 


224  Mental  Deficiency 


SCLEROTIC  AMENTIA. 

It  has  already  been  remarked  that  proliferation  of  neuroglia, 
resulting  in  sclerosis,  is  found  post-mortem  in  a  considerable 
number  of  cases  of  both  the  primary  and  secondary  forms  of 
amentia.*  In  many  of  these  it  is  a  pathological  condition  which 
has  no  clinical  significance,  and  gives  rise  to  no  definite  symptoms 
by  which  its  presence  may  be  diagnosed,  or  even  suspected, 
during  life.  In  a  small  proportion  of  cases,  however,  the  neurog- 
liosis  attains  such  magnitude  as  to  produce  a  tolerably  readily 
recognizable  type  of  amentia,  and  these  we  shall  here  describe. 

Regarding  the  etiology  of  these  cases  our  knowledge  is  still 
imperfect,  and  it  is  probable  that  the  same  result  may  be  produced 
by  different  causes.  In  many — indeed,  I  think,  in  the  majority 
of  cases — inquiries  into  the  family  history  reveal  the  presence  of 
alcoholism,  phthisis,  insane  and  epileptic  heredit}^,  precisely  the 
same  as  in  ordinary  cases  of  primary  amentia  ;  but  in  addition 
there  is  often  a  history  of  birth  injury  or  other  vascular  or  toxic 
lesioiLpf  early  infancy  which  may  possibly  act  as  a  determin- 
ing influence.  In  a  few  cases  the  latter  conditions  alone  are 
present.  But  although  it  seems  probable  that  in  the  majority  of 
cases  sclerosis  is  determined  by,  and  the  after-effect  of,  some 
diseased  (vascular  or  toxic)  condition  of  the  brain,  it  may  in  a 
small  number  of  instances  arise  independently  of  such  conditions 
in  consequence  of  primarily  imperfect  neuronic  development. 
However  produced,  and  whether  the  amentia  be  a  primary  one 
complicated  by  sclerosis,  or  whether  the  sclerosis  is  itself  the 
cause  of  the  amentia,  the  result  is  pretty  much  the  same.  And 
since  the  special  chnical  symptoms  in  these  cases  are  in  the  main 
referable  to  the  sclerosis,  and  since,  moreover,  the  cases  resemble 
many  of  the  pure  secondary  forms  in  their  tendency  to  degenera- 
tion and  dementia,  it  seems,  on  the  whole,  preferable  to  describe 
sclerotic  amentia  in  this  place. 

There  are  two  chief  clinical  types  of  this  variety  of  amentia, 
dependent  upon  whether  the  sclerosis  is  general  and  diffuse^or 
occurs  in  Idealized  patches.  This  division  is,  perhaps,  not  an 
absolute  one,  an3~CcCses^f  diffuse  sclerosis  have  been  described  in 

♦  See  Chapter  IV.,  Pathology. 


Secondary  Amentia  and  its  Clinical  Varieties  225 

which  the  condition  was  confined  to  one  hemisphere.  Neverthe- 
less, there  are  certain  cUnical  differences  in  the  two  forms  which 
sufficiently  justify  such  a  distinction. 

In  cases  of  di-fftise  sclerosis  the  dominating  symptoms  are 
general  muscular  weakness,  often  accompanied  by  spastic  rigidity 
and  feeble  contractures,  but  rarely  by  actual  paralysis.  There 
is  also  marked  tremor,  but  not  often  definite  convulsions.  In 
hocalized,  nodular,  or  hiberous  sclerosis,  on  the  other  hand,  there 
are  usually  frequent  epileptic  fits  without  paralj^is  or  contrac- 
Tures,  although  movements  are  often  tottering  and  tremulous,  and 
in  these  latter  cases  death  often  results  from  a  succession  of  fits. 

Extensive  gliosis,  in  the  first  instance,  produces  an  enlargement 
of  the  brain,  and  in  this  way  gives  rise  to  a  clinical  variety  of 
amentia2__wJuch-4s4«iowfl~'as  "  hypertrophic."  With  the  lapse  of 
time,  however,  the  neuroglia  tends  to  contract,  and  there  is  then 
produced  a  regular  or  irregular  form  of  bram  atrophy.  The 
hypertrophic  brain  never  tends  to  indefinite  enlargement  as  does 
the  hydrocephalic,  and  the  effect  of  time  in  bringing  about  con- 
traction of  the  glia  tissue  is  weU  seen  in  the  central  umbilication 
which  takes  place  in  the  tuberous  areas  of  the  locahzed  form. 
This  feature  of  the  neuroglia  is  seen  in  other  diseases;  for  in- 
stance, the  spinal  cord  in  the  early  stage  of  extensive  disseminated 
sclerosis  is  greatly  swollen,  whilst  in  the  later  stages  it  becomes 
exceedingly  small,  shrivelled,  and  distorted. 

Diffuse  Sclerosis. 

Cases  of  amentia  accompanied  by  diffuse  sclerosis  fall  into 
two  groups,  dependent  upon  whether  cranial  enlargement  is  or 
is  not  a  prominent  feature.  We  may  therefore  describe  atrophic 
and  hypertrophic  forms.  But,  as  already  stated,  it  is  doubtful 
whether  there  is  any  essential  pathological  difference  between 
these  two  forms,  and  the  clinical  difference  is  probably  dependent 
upon  the  extent  and  rapidity  with  which  neurogUal  increase  takes 
place  whilst  the  cranial  bones  are  yet  ununited.  Where  synostosis 
has  not  occurred,  so  that  expansion  of  the  skull  may  allow  of 
cerebral  enlargement,  the  prognosis  as  to  life  and  response  to 
training  is  much  more  favourable  than  where  the  bones  offer  an 
unyielding  resistance. 

15 


226  Mental  Deficiency 

(a)  Atrophic  Form. — ^These  cases  are  very  rare.  In  those 
hitherto  recorded  the  mental  deficiency  has  usually  been  of  a 
pronounced  grade,  and  although  there  may  be  some  slight  re- 
sponse to  training  at  first,  progressive  dementia  supervenes  sooner 
or  later.  Definite  convulsions  are  uncommon,  but  a  condition 
of  muscular  tremor  is  always  present.  This  varies  from  a  more 
or  less  constant  shaking  of  the  head  to  an  incessantly  repeated 
^ne  tremor  of  the  whole  body.  It  is  incTeciLsed  under  observation 
or  voluntary  effort,  and  is  often  described  as  chorea  ;  but  it  is 
more  akin  to  the  tremor  of  paralysis  agitans.  In  addition  there 
is  a  general  muscular  weakness,  with  spasm  and  incomplete  con- 
tractures of  the  arms  or  legs,  but  there  is  rarely  actual  paralysis. 
The  reflexes  are  increased.  In  some  cases  both  epileptic  convul- 
sions and  paralysis  ai  e  present,  and  Bourneville*  has  described  a 
case  in  which  these  were  at  first  limited  to  one  side  of  the  body ; 
but  at  the  age  of  thirteen  classic  epilepsy  appeared,  and  the 
patient  died,  aged  twenty-one,  in  status  epilepticus.  The  post- 
mortem examination  showed  atrophy  and  sclerosis  of  the  whole 
of  one  hemisphere. 

Illustrative  Cases. 
Disuse  Sclerotic  Amentia  with  Pimz^ssive  D^M^^dja.f — E.  G., 


female,  was  admitted  to  Darenth  Asylum  at  the  age  of  twelve 
years.  No  history  obtainable.  Her  mental  status  was  that  of 
ap  imbecilej;iiitsight  and  hearing  were  good,  and  she  possessed 
aTgooJinernory for'tcFcci!».  Opeech was \'ery scaiity , ' ilffd was  slow 
and  hesitating.  Habits  cleanly.  She  was  described  as  a  cripple, 
but  not  paralyzed.  There  was  general  muscular  weakness  of  all 
the  limbs,  so  that  she  was  unable  to  wash,  dress,  feed,  or  do 
anything  for  herself.  In  addition  there  was  a  sHght  shaking 
movement  of  the  head.  She  spent  all  her  time  sitting  in  a  chair, 
but  she  noticed  what  went  on  round  her.  The  cranial  circum- 
ference was  19 J  inches. 

After  a  time  the  shaking  movements  of  the  head  increased,  and 
eventually  extended  to  all  the  limbs.    There  were,  however, 

*  Bourneville,  "Sclerose  Cerebrale  Hemispherique,"  Archives  de  Neuro- 
logic, 1897,  vol.  iii. 

■j-  For  the  clinical  notes  of  this  case  I  am  indebted  to  Dr.  F.  R.  P.  Taylor, 
formerly  Medical  Superintendent  of  Darenth  Asylum. 


Secondary  Amentia  and  its  Clinical  Varieties  227 

never  any  definite  convulsions.  The  muscular  helplessness 
also  increased,  and  the  arms  and  legs  became  sUghtly  con- 
tracted at  the  elbows  and  knees  respectively.  She  became 
duller  mentally,  less  observant,  and  wet  and  dirty  in  her  habits. 
Finally  her  temperature  suddenly  ran  up  to  104°  F.,  and  her  pulse 
to  180,  and  she  gradually  sank  and  died  without  any  signs  of 
disease  other  than  the  cerebral  sclerosis.  Her  age  at  death  was 
twenty  years. 

Post-mortem  examination  failed  to  reveal  disease  of  any  organ 
other  than  the  brain.  The  dura  mater  was  thick  and  congested  ; 
the  pia  thick  and  opaque,  but  non-adherent.  The  whole  brain 
was  small,  but  heavy  for  its  size,  weighing  32  ounces.  Its  con- 
sistence was  extremely  dense — in  fact,  almost  like  cartilage. 
Upon  making  a  microscopical  examination  I  found  that  the  whole 
of  the  hemispheres,  the  white  as  well  as  the  grey  matter,  were 
the  site  of  a  dense  diffuse  sclerosis  ;  the  cerebellum  w^as  similarly 
involved. 

The  following  very  similar  case  is  described  by  Dr.  O. 
Heubner :  * 

The  patient,  a  boy  of  five  years,  seemed  bodily  and  mentally 
sound  until  the  age  of  three  and  a  half  years,  except  that  he  was 
late  in  learning  to  speak,  and  could  not  talk  fluently.  The  family 
was  said  to  be  healthy.  Apparently  as  the  result  of,  or  at  any 
rate  after,  a  fall  on  the  back  of  the  head,  he  no  longer  played 
willingly,  and  was  often  apathetic.  Nine  months  afterwards 
appeared  a  slothfulness  of  all  movement,  and  his  walk  became 
staggering.  This  was  followed  by  spastic  paralysis  of  the  legs, 
with  contractures  at  the  hips  and  knees,  and  double  equino- yarns. 
Strong  intention  tremors  then  appeared  in  the  arms,  also  followed 
by  spastic  paralysis.  There  was  difliculty  in  swallowing,  so  that 
he  could  only  take  liquids,  and  eventually  he  became  unable  to 
speak.  There  was  constant  movement  of  the  head  and  upper 
extremities,  and  there  was  slight  paresis  of  the  lower  part  of  the 
right  face.  He  became  progressively  weaker  in  mind,  but  able  to 
recognize  people  he  knew,  and  there  was  no  observable  alteration 
in  general  or  special  sensation.  The  knee-jerks  were  increased, 
electrical  reactions  normal,  and  there  was  incontinence  of  urine 

*  O.  Heubner,  "  Ueber  diffuse  Hirnsklerose,"  Chariti-annalen,  iSgy, 
xxii. 

15—2 


22  8  -  Mental  Deficiency 

and  faeces.  He  became  much  emaciated,  and  died  of  broncho- 
pneumonia. 

Post-mortem  examination  revealed  a  pale-yellow  brain  of 
unusual  hardness  throughout,  the  white  and  grey  substances,  as 
well  as  the  cerebellum,  being  extensively  involved  by  sclerosis. 

The  two  following  cases  of  brother  and  sister,  who  were  kindly 
shown  to  me  at  Daren th  Asylum  by  Dr.  F.  R.  P.  Taylor,  are 
probably  examples  of  diffuse  cerebral  sclerosis. 

The  mother  of  these  patients  is  healthy,  but  the  father  is  insane 
in  an  asylum.  The  father  and  mother  are  first  cousins  ;  the 
mother's  father  and  mother  were  also  first  cousins.  There  have 
been  fourteen  children  born  in  the  family — five  are  dead  and 
nine  living  ;  there  is  "  something  the  matter  with  all  of  them," 
and  at  least  one  other  is  mentally  defective. 

Rose,  the  eldest  patient,  was  born  prematurely  at  the  seventh 
month,  and  she  has  been  abnormal  from  birth.  She  commenced  to 
say  a  few  words  when  about  two  years  of  age,  and  made  attempts 
to  walk  at  three ;  but  she  never  made  much  progress,  and  at  the 
age  of  twelve  years,  on  account  of  the  mental  deficiency  and  con- 
stant tremor,  she  was  sent  to  the  asylum.  She  proved  uneducable, 
and  the  tremor  steadily  became  worse.  When  I  saw  her  at  the 
age  of  twenty-one  years  she  was  a  bright -looking  girl,  apparently 
quite  happy  and  contented,  but  of  markedly  limited  mental 
power.  She  understood  a  good  deal  of  what  was  said  to  her,  and 
made  attempts  to  reply  ;  but  her  articulation  was  quite  unin- 
telligible on  account  of  the  tremor.  She  spent  the  day  sitting  in 
a  chair,  and  was  quite  unable  to  walk,  or  even  stand,  without 
support.  There  was  spastic  rigidity,  with  inversion  and  adduc- 
tion of  both  legs  and  feet  ;  the  knee-jerks  and  plantar  reflexes 
were  exaggerated,  and  ankle  clonus  was  well  marked.  The  head 
was  never  still  in  consequence  of  constant  rhythmic  up-and-down 
and  side-to-side  movements  ;  the  facial  muscles  were  also  affected, 
giving  rise  to  a  never-ending  series  of  extraordinary  grimaces. 
These  movements  were  described  as  chorea,  but  they  really  had 
greater  resemblance  to  paralysis  agitans.  They  were  worse 
under  observation,  but  ceased  during  sleep. 

The  brother,  WilHam,  was  very  similar,  except  that  in  his  case 
the  rhythmic  movements  affected  the  whole  body — head,  face, 
arms,  hands,  and  legs.     It  was  impossible  for  him  to  pick  any- 


Secondary  Amentia  and  its  Clinical  Varieties  229 

thing  up,  or  to  retain  anything  in  his  hands,  but  the  grasp  of  the 
hands  showed  that  tolerable  muscular  strength  was  present. 
He  understood  what  was  said  to  him,  and  attempted  to  reply,  but 
his  words  were  quite  unintelligible.  He  had  a  moderate  amount 
of  intelligence,  and  obviously  observed  what  was  going  on  round 
him,  and  he  was  quite  clean  in  his  habits. 

(b)  Hypertrophic  Form. — This  condition  is  sometimes  described 
as  hypertrophy  of  the  brain,  but  it  is  to  be  borne  in  mind  that  the 
"hyperirdphy  concerns  the  interstitial  tissue  only,  and  not  the 
cerebral  neurones — that  it  is,  in  fact,  a  (probably  diffuse)  ghosis. 

Hypertrophic  amentia  is  relatively  rare,  and  is  characterized 
by  an  enlargement  of  the  brain  and  skull  and  by  certain  bodily 
and  mental  symptoms.  The  largest  skull  of  this  variety  I  have 
seen  had  a  circumference  of  25  inches.  Owing,  however,  to  an 
increase  4Ti-4he  density-  as  .weU-a»-  the  size,  the  brain  weight  is 
often  considerably  greater  than  would  be  expected  even  from 
the  size  of  the  skull.  Dr.  Fletcher  Beach  found  the  brain  of  a 
boy  who  died  at  the  age  of  fifteen  to  weigh  62  ounces.  Dr.  Ireland 
quotes  two  cases  described  by  Dr.  Daniel  Brunet.  The  brain 
of  one,  at  the  age  of  seventeen,  weighed  1,632  grammes  ;  that  of 
the  other,  dying  at  the  age  of  eighteen,  weighed  1,780  grammes. 

Owing  to  the  cranial  enlargement,  these  cases  are  sometimes 
mistaken  for  hydrocephalus  ;  but,  as  pointed  out  by  Dr.  Fletcher 
Beach,  there  are  readily  recognizable  differences.  The  skull  of 
the  hypertrophic  ament  tends  to  be  square  in  shape  instead  of 
round,  and  there  are  sometimes  well-marked  frontal  prominences. 
In  hypertrophy,  the  greatest  circumference  is  at  the  level  of  the 
superciliary  ridges,  whereas  in  hydrocephalus  it  is  greatest  over 
the  temples.  Thus,  although  the  skull  of  the  hypertrophic 
patient  looks  massive,  it  has  not  that  "  top-heavy  "  appearance 
so  characteristic  of  the  hydrocephalic.  Further,  in  hydro- 
cephalus there  is  usually  bulging  of  the  fontanelle  and  sutures, 
whilst  in  hypertrophy  this  is  not  generally  the  case  ;  in  fact,  the 
expansile  effects  and  the  tendency  to  distend  the  skull  seem  to 
be  much  greater  in  the  former  than  in  the  latter  condition.  The 
cranium,  having  reached  a  certain  limit,  ceases  to  further  expand, 
in  consequence  of  the  contraction  of  the  neuroglia  ;  whilst  hydro- 
cephalus tends  to  expand  the  skull  indefinitely. 

Hypertrophic  amentia  is  usually  accompanied  by— headache. 


230  Mental  Deficiency  - 

which  may  be  very  severe,  and  by  epileptic  fits.  In  some  cases 
the  fits  diminish  in  frequency  and  severity,  and  they  may  entirely 
cease.  In  others  they  get  steadily  worse,  and  many  patients 
ultimately  die  of  exhaustion  following  a  series  of  fits.  In  a  con- 
siderable number  there  is  a  general  muscular  weakness  of  all 
parts  of  the  body,  so  that  the  balance  is  unsteady,  the  walk  slow 
and  tottering,  and  the  grasp  feeble.  Tremor  -is  often  brou^g^ht 
out  by  exertion.  In  consequence,  manual  work  is  performed 
slowly,  clumsily,  and  with  considerable  difiiculty.  Speech  is 
often  similarly  affected.  Most  of  the  cases  I  have  seen  have 
been  somewhat  undersized,  heavy-looking  and  of  good  bodily 
nutrition,  also  of  cheerful  although  somewhat  simple  expression. 
The  degree  of  mental  defect  varies  very  much,  and  seems  to 
be  dependent  upon  the  frequency  with  which  convulsions  occur. 
"Where  these  are  slight,  it  is  usually  one  of  mild  imbecility,  or 
even  merely  feeble-mindedness  ;  but  if  the  fits  are  at  all  fre- 
quent, a  condition  amounting  to  idiocy  may  be  present.  Attacks 
of  rage  and  violence  have  been  described,  but  these  are  by  no 
means  constant,  and  I  doubt  whether  they  are  any  more  common 
in  this  than  in  other  varieties  of  amentia.  Certainly  some  of 
these  persons  are  harmless  and  thoroughly  good-tempered.  The 
severe  cases,  which  are  accompanied  by  frequent  fits,  seem  to 
die  early,  and,  as  far  as  one  can  judge  from  the  cases  which  have 
been  recorded,  few  survive  long  after  maturity.  This,  however, 
is  by  no  means  so  with  the  milder  forms,  in  whom  fits  are  com- 
paratively rare,  and  at  the  present  time  there  is  one  of  these 
patients  in  Earlswood  Asylum  who  is  fifty-two  years  of  age,  and 
seemingly  in  excellent  health. 


Illustrative  Cases. 


W.  C.  T^Jmale  ;  the  only  child  ;  no  morbid  heredity.  He 
m  every  way  normal  until  three  years  of  age,  when  he 
had  an  acute  illness,  which  the  mother  calls  "  influenza  and 
rheumatic  fever."  It  was  accompanied  by  fever  and  very  great 
pain  in  the  head.  He  went  to  school  at  the  age  of  seven,  and 
left  at  fifteen.  Was  in  the  fourth  standard,  but  his  mother 
admits  that  he  was  very  dull  at  learning,  and  does  not  think 
he  was  equal  to  fourth  standard  work.     He  had  whooping-cough 


Secondary  Amentia  and  its  Clinical  Varieties  231 

at  the  age  of  nine,  which  was  accompanied  by  six  fits.  There 
were  no  further  fits  until  twelve  years  of  age,  but  during  this 
time  he  was  noticed  to  be  very  unsteady  in  standing  and  walking, 
and  he  would  frequently  fall  down  both  in  and  out  of  school. 
In  addition  to  being  somewhat  dull,  he  was  prone  to  outbreaks 
of  bad  temper  and  irritability,  and  was  at  times  spiteful.  The 
head  was  first  noticed  to  be  larger  than  usual  after  the  attack  of 
whooping-cough  at  nine  years. 

I  first  saw  him  when  he  was  fifteen  years  of  age.  He  was 
undersized,  but  fat  and  heavy.  The  circumference  of  the  skull 
at  the  level  of  the  supra-orbital  ridges  was  23  inches  ;  there  was 
no  asymmetry  and  no  prominences  ;  the  fontanelles  were  closed. 
The  upper  and  lower  jaw-bones  were  also  larger  than  usual, 
and  as  a  result  there  were  large  gaps  between  the  teeth.  The 
teeth  themselves  were  poorly  developed,  and  many  were  decayed. 
The  palate  was  broad  and  shallow.  The  nose  was  strikingly 
broad,  with  prominent  fleshy  nostrils  ;  the  lips  were  thick  and 
fleshy,  and  the  mouth  large.  The  tongue  appeared  quite  normal, 
but  was  always  protruded  markedly  to  the  right  side.  There 
was  nothing  abnormal  about  ears  or  eyes.  The  external  genitals 
were  well  developed,  and  there  was  an  abundance  of  pubic  hair. 
There  was  considerable  rigidity  of  the  hands,  arms,  and  legs. 
No  actual  paralysis  was  present,  but  the  left  hand,  arm,  and  leg 
were  definitely  weaker  than  the  right,  and  he  walked  with  a 
well-marked  limp.  The  knee-jerks  could  not  be  obtained,  but 
both  plantar  reflexes  were  exaggerated,  particularly  the  left. 
Whilst  under  examination  there  were  almost  constant  irregular 
jerky  movements  resembling  chorea ;  these  also  were  most 
marked  on  the  left  side.  He  was  subject  to  tonic  convulsions^ 
averaging  four  or  five  daily.  During  these  the  right  eye  was 
firmly  closed  and  the  face  drawn  to  the  right,  the  left  eye  being 
open.  Legs  and  arms  were  rigid  and  drawn  up  on  to  the  trunk. 
No  clonic  movements  and  no  loss  of  consciousness.  There  were 
no  sensory  defects,  memory  was  good,  attention  rather  fitful. 
He  understood  all  that  was  said  to  him,  and  could  converse  quite 
rationally,  although  his  speech  was  thick,  slow,  and  hesitating. 
He  used  to  stutter  a  great  deal,  but  not  now.  He  could  read 
and  write,  but  was  exceedingly  poor  at  sums.  He  had  con- 
siderable   moral    and   religious   sense,   and   was   obedient   and 


232  Mental  Deficiency 


well-behaved.       His    mental   status    was   one   of    mild   feeble- 
mindedness. 

He  is  now  twenty-one  years  of  age,  and  has  been  under  my 
observation  for  six  years.  At  the  present  time  the  cranial  cir- 
cumference over  the  supra-orbital  ridges  is  23!  inches,  over  the 
brow  23!  inches.  His  height  is  5  feet,  weight  9  stones,  and  there 
is  practically  no  alteration  in  his  appearance.  There  have  been 
no  convulsions  for  several  years,  but  if  he  gets  upset  or  excited 
the  hands  and  arms  become  rigid  and  are  drawn  up  on  to  the 
chest.  His  walk  is  slow  and  somewhat  tottering,  and  his  balance 
is  unsteady  ;  but  if  he  is  allowed  to  take  his  time  he  can  walk 
several  miles.  He  can  do  odd  jobs,  and  can  clean  a  pair  of 
boots,  but  it  takes  him  an  hour  to  do  so.  If  he  is  hurried  a 
general  muscular  tremor  sets  in,  which  makes  work  impossible. 
His  hand-grasps  are  fairly  good  ;  the  legs  are  spastic.  He  fre- 
quently complains  of  headache,  which  he  refers  to  the  parietal 
eminences.  There  is  a  decided  improvement  in  his  mental  con- 
dition, and  he  can  do  many  small  jobs  about  the  house.  He 
can  carry  a  parcel  or  a  message,  but  his  mother  says  that  he 
cannot  be  trusted  to  do  shopping,  as  he  gets  into  a  hopeless 
muddle  with  the  change.  His  temper  is  irritable  and  perverse 
at  times,  but  on  the  whole  he  is  obedient  and  gives  no  trouble. 
I  have  got  him  into  several  situations,  but  he  has  been 
discharged  from  each  in  turn  in  consequence  of  his  general 
incompetence. 

It  is  worthy  of  note  that  the  increased  size  of  the  jaws,  with 
the  separation  of  the  teeth  and  the  large  and  broad  nostrils,  give 
rise  to  a  physiognomy  somewhat  resembling  acromegaly.  There 
are,  however,  no  other  signs  of  that  condition,  and  the  early 
onset  is  totally  unlike  it.  It  is  quite  possible,  however,  that  the 
signs  which  are  present  may  be  due  to  a  partial  sclerosis  of  the 
pituitary  gland. 

I  have  quoted  this  case  somewhat  in  detail  because  it  seems 
to  me  to  be  a  very  typical  example  of  that  form  of  hypertrophic 
amentia  in  which  fits  have  not  produced  serious  mental  degrada- 
tion. At  the  present  time  there  is  a  very  similar  case  in  Earls- 
wood  Asylum,  and  another  patient  of  this  type  whom  I  have 
known  for  over  ten  years  has  managed  during  that  time  to  earn 
his  keep  as  a  tradesman's   boy.     In  this   case,   however,   the 


Plate  XVIII. 
SECONDARY  AMENTIA   DUE  TO  SCLEROSIS. 


Fig.  45. — A  case  of  so-called  '^^  hypertrophy  of  the  brain."     Ag-e,  21  years. 


Fig,  46. — Hydrocephalic  and  microcephalic  imbeciles. 
To  face  page  232.] 


/-■-< 


■>J^ 


Secondary  Amentia  and  its  Clinical  Varieties  233 

amentia  is  less  marked,  and  his  employer  has  treated  him  with 
considerable  indulgence. 


Tuberous  or  Nodular  Sclerosis. 

In  this  form  of  sclerosis  convulsions  are  usually  the  first 
symptom  to  attract  attention,  being  noticed  towards  the  end  of 
the  first  year.  In  a  few  cases,  however,  they  are  preceded  by 
irregular  muscular  twitching  or  head-nodding.  They  continue 
during  the  life  of  the  patient  with  tolerable  frequency,  in  some 
cases  occurring  daily,  in  others  at  intervals  of  a  few  days.  They 
are  indistinguishable  from .  ordinary  idiopathic  epilepsy,  and 
minor  attacks  often  occur  as  well.  Mental  impairment  is  noticed 
in  the  early  years  of  life,  and  varies  from  a  condition  of  mild 
imbecility  permitting  of  some  training,  to  a  more  pronounced 
imbecility  or  idiocy ;  usually  it  is  of  a  severe  grade.  Hea(;iache 
is  often  present,  and  attacks  of  excitement,  rage,  and  destructive- 
ness  are  common.  Muscular  tremor  is  usually  present,  and  the^ 
baTaii(!tJ  UVA.y  Ut^.  nnsteadv  and  the  gait  tottering  ;  but  definite 
rigidity  and  contractures,  like  those  met  with  in  the  diffuse 
v^iety;  are  albsent.  There  are  no  sensor}/  disturbances.  Pro- 
gressive dementia  supervenes,  and  death  usually  takes  place  in 
status  epilepticus  before  the  age  of  maturity^. 

Illustrative  Cases. 

WC^,  male.  Father  insane  ;  father's  mother  epileptic  and 
insane.  The  patient  has  been  subject  to  epileptic  fitssmce  a 
year  old.  He  has  always  been  of  deficient  intellect,  and  was 
ttftabk-to  learn  at  school.  He  was  subject  to  attacks  of  excite- 
ment  and  violence,  and,  according  to  his  mother,  would  take 
up  a  knife  to  anyone  on  the  slightest  provocation.  At  the  age 
of  thirteen  he  became  so  troublesome  that  he  had  to  be  sent  to 
the  asylum.  On  admission  he  was  found  to  be  a  pronounced 
imbecile,  possessing  numerous  stigmata  of  degeneracy.  He 
understood  what  was  said  to  him,  and  was  able  to  converse, 
but  in  a  very  simple  and  childish  manner.  He  had  a  great 
fancy  for  drawing,  but  no  ability.  He  was  subject  to  frequent 
epileptic  fits  and  occasional  paroxysms  of  excitement.  There 
was  no  paralysis.     His  memory  gradually  became  defective  and 


2  34  Mental  Deficiency 

his  articulation  indistinct.  Salivation  was  constant.  He  became 
more  and  more  demented,  and  died  at  the  age  of  nineteen  from 
exhaustion  consequent  upon  status  epilepticus  lasting  seven  days. 
During  this  time  he  had  406  convulsions. 

.--^I'oiF-moffS  examination  showed  a  dense,  thick,  symmetrical 
skull,  with  a  small  but  heavy  brain,  which  weighed  1,445  grammes. 
The  membranes  appeared  normal,  and  there  was  no  excess  of 
cerebro-spinal  fluid.  Both  hemispheres  were  studded  with 
numerous  protuberances  of  pale  sclerotic  tissue,  from  which  the 
pi  a  arachnoid  stripped  with  unusual  readiness.  These  nodules 
varied  from  the  size  of  a  pea  to  that  of  a  small  walnut  ;  many  of 
them  were  extremely  hard  to  the  touch,  and  such  were  marked 
by  a  central  umbilication,  evidently  due  to  contraction.  They 
were  strictly  confined  to  the  grey  matter,  the  most  careful 
examination  failing  to  reveal  them  in  the  centrum  ovale. 
Histologically,  these  nodules  consisted  of  neuroglia  cells  and 
fibres  in  various  stages  of  growth  ;  a  few  contained  indications 
of  former  haemorrhages  in  the  presence  of  hsematoidin  crystals. 
The  few  nerve  cells  present  were  very  irregular  in  arrangement, 
as  well  as  being  atrophied  and  distorted.  The  lamination  of  the 
adjacent  cortex  also  was  much  disturbed,  and  there  were  many 
nerve  cells  in  a  condition  of  imperfect  development,  as  well  as 
others  undergoing  chronic  pigmentary  atrophy.  Other  portions 
of  the  cortex  which  were  not  occupied  by  nodules  were  sur- 
mounted by  a  definite  band  of  sclerotic  tissue,  this  being  situated 
immediately  underneath  the  pia-arachnoid  membrane.  The 
corpora  striata  also  were  studded  with  protuberances  of  fine  glia 
tissue,  ranging  in  size  from  a  grape-stone  to  a  large  pea  ;  but  the 
ventricles  were  not  dilated,  and  the  ependyma  was  normal. 
Several  of  the  leaflets  of  the  lobus  clivi  of  the  cerebellum  were 
markedly  atrophied,  and  in  these  the  number  of  Purkinje's 
cells  was  much  diminished.  There  was  also  slight  interstitial 
sclerosis  of  the  pyramidal  tracts  and  antero -lateral  columns  of 
the  spinal  cord.  These  lesions  of  the  cerebellum  and  cord  were 
probably  secondary  to  the  cortical  sclerosis. 

A  case  presenting  identical  histological  features  to  the  above 
was  described  by  Dr.   Joseph  Sailer.*     In  this  there  was  an 

*  J.    Sailer,    "  Hypertrophic   Nodular   Gliosis,"    American   Journal    of 
Nervous  and  Mental  Disease,  1898,  p.  402. 


Secondary  Amentia  and  its  Clinical  Varieties  235 

insane  and  alcoholic  heredity,  and  spasms  began  at  the  age  of 
ten  months.  The  mental  condition  was  one  of  low-grade  idiocy. 
Epileptic  convulsions  were  frequent,  and  the  patient  died,  aged 
fifteen,  of  exhaustion  after  a  succession  of  fits. 

Another  similar  case  was  described  by  Dr.  Margaret  B.  Dobson.* 
In  this  there  was  a  marked  family  history  of  tuberculosis,  alco- 
holism, and  epilepsy,  and  the  patient,  a  male  epileptic  idiot,  died 
at  the  age  of  ten  years  from  pneumonia  accelerated  by  exhaus- 
tion from  epilepsy.  The  post-mortem  appearances  were  similar 
to  those  already  described. 

HYDROCEPHALIC  AMENTIA. 

Primary  amentia  may  be  complicated  by  hydrocephalus,  and 
this  condition  is  even  occasionally  found  in  making  post-mortem 
examinations  of  microcephalics.  The  term  "  hydrocephalic 
amentia,"  however,  is  better  restricted  to  those  cases  in  which 
the  mental  deficiency  is  secondary  to  this  lesion. 

As  to  the  cause  of  hydrocephalus  much  uncertainty  exists.' 
Some  cases  are  the  after-effect  of  chronic  meningitis  or  tumours' 
(usually  syphilitic  or  tubercular)  of  the  base  of  the  brain  ;  in 
others  no  antecedent  lesion  can  be  discovered.  However  pro- 
duced, the  essential  condition  consists  of  an  accumulation  of 
cerebro-spinal  fluid,  which  may  amount  to  several  pints,  within 
the  ventricles  of  the  brain.  In  consequence  of  the  pressure  of 
this  fluid,  the  brain  tissue  adjacent  to  the  ventricles  is  gradually 
thinned  and  destroyed.  In  extreme  cases  it  may  be  reduced 
to  a  mere  shell  but  a  fraction  of  an  inch  in  thickness,  so  that 
the  hemispheres  resemble  a  huge  cyst.  The  parts  least  affected 
are  the  cerebellum  and  basal  ganglia. 

The  expansile  force  of  the  fluid  is  usually  marked  upon  the 
skull,  the  bones  of  which  become  widely  separated  ;  and  this, 
with  the  general  enlargement,  produces  a  clinical  picture  which 
cannot  well  be  mistaken.  But  in  some  instances  hydrocephalus 
may  exist  with  a  small  skull,  owing  to  premature  ossification  of 
the  cranial  bones,  and  the  condition  will  then  only  be  revealed 
after  death.  Such  are  usually  pronounced  idiots  ;  convulsions 
are  frequent,  and  death  takes  place  early. 

*  Margaret  B.  Dobson,  "  A  Case  of  Epileptic  Idiocy,"  etc.,  Lancet, 
December  8,  1906. 


236  Mental  Deficiency 

Occasionally  hydrocephalus  exists  before  birth,  but  if  at  all 
severe  it  is  rarely  possible  for  the  child  to  be  born  alive  ;  and  in 
the  majority  of  cases  met  with  the  onset  takes  place  in  the  first 
few  months,  or  it  may  be  years,  of  life.  There  can  be  no  doubt 
that  a  great  proportion  of  children  so  affected  die  within  a  few 
years.  In  other  cases  a  spontaneous  cure  takes  place,  and  it  has 
even  been  affirmed  by  Edinger  that  a  mild  hydrocephalus  occur- 
ring in  childhood,  and  not  progressing,  may  actually  favour 
mental  development  by  causing  a  lessened  resistance  to  the 
growth  of  the  brain.  In  most  cases,  however,  there  results  some 
degree  of  mental  deficiency. 

The  subsequent  course  differs,  and  in  the  main  there  are  two 
types.  In  one,  whilst  the  patient  may  be  imbecile,  or  even 
idiotic,  the  mental  condition  is  of  secondary  importance,  in  view 
of  the  active  and  steadily  progressive  nature  of  the  disease  to 
which  it  is  due.  Such  children  are  acutely  ill,  the  body  is 
wasted,  convulsions  are  frequent,  and  severe  paralysis  is  generally 
present.  Many  of  them  are  bedridden.  They  may  be  blind  or 
deaf  from  the  pressure  of  fluid,  and  optic  atrophy  is  often  seen. 
Although  the  alienist  may  be  consulted  with  regard  to  these 
cases,  their  place  is  the  hospital  ward,  and  not  the  special  institu- 
tion, and  death  soon  closes  the  scene.  In  some  instances  con- 
siderable amelioration  of  the  mental  symptoms  takes  place 
immediately  before  death. 

The  second  type,  those  cases  usually  seen  in  special  institu- 
tions, or  which  come  under  notice  on  account  of  amentia,  are 
those  in  which  the  hydrocephalus  is  either  increasing  very  slowly 
or  has  undergone  spontaneous  arrest.  In  these  cases  the  mental 
deficiency  varies  from  a  mild  degree  of  feeble-mindedness  to  pro- 
nounced imbecility,  and,  as  a  rule,  a  moderate  amount  of  improve- 
ment takes  place  as  a  result  of  special  training.  Dr.  Ireland 
quotes  the  case  of  a  boy  under  his  care  who  lost  his  hearing  after 
being  several  years  at  Larbert,  and  gradually  lost  many  of  the 
words  he  had  learned.  *'  He  was  taught  a  number  of  figurative 
signs,  and  also  to  spell  on  his  fingers ;  and  although  he  had  the 
additional  disadvantage  of  obscurity  of  sight — ^having  dimness  of 
the  cornea,  resulting  from  ophthalmia — his  progress  was  as  well 
marked  as  thatfoffanyZpupiHimthe  establishment." 

The  majority  of  hydrocephalic  aments  are  quiet,  confiding, 


Plate  XIX. 
SECONDARY   AMENTIA   DUE  TO   HYDROCEPHALUS. 


Fig.  47. — Male  hydrocephalic.     A^e,  i§  years. 
(From  a  photograph  lent  by  Dr.  J.  Thomson^ 

MICROCEPHALIC  AMENTIA. 


Fig.  48. — Female  microcephalic.     Ag-e,  4I  months. 
{From  a  photograph  lent  by  Dr.  J.  Thomson!) 
To  face  page  236.] 


>-, 


OF         y 


Secondary  Amentia  and  its  Clinical  Varieties  237 

affectionate,  and  obedient,  and  although  paresis  may  prevent  the 
performance  of  much  in  the  way  of  manual  work,  they  are  usually 
very  willing  to  do  what  they  can.  Owing  to  their  muscular 
weakness,  movements  are  clumsy  and  badly  co-ordinated,  and  in 
some  cases  severe  paralysis  may  be  present.  The  legs  are  more 
frequently  and  more  severely  involved  than  the  arms.  Impair- 
ment of  sight  and  hearing  are  also  common  ;  strabismus  is  fre- 
quent ;  and  in  the  more  severe  cases  nystagmus  occurs.  Epileptic 
convulsions  are  usually  present  in  the  acute  stage,  but  tend  to 
diminish,  and  often  disappear  altogether,  in  the  chronic  cases 
seen  in  institutions.  Most  patients  are  undersized,  but  there 
are  no  stigmata  of  degeneracy.  (See  Plates  XVIII.  and  XIX., 
Figs.  46  and  47.) 

The  peculiar  enlargement  of  the  skull  makes  diagnosis  easy. 
The  hydrocephalic  skull  is  uniformly  increased  in  all  directions, 
and  thus  tends  to  assume  a  globular  shape.  The  forehead  is  high 
and  projecting,  and  there  is  usually  a  characteristic  bulging  at 
the  root  of  the  nose,  but  the  greatest  circumference  is  at  the  level 
of  the  temples.  The  fontanelle  is  tense,  and  the  sutures  often 
widely  separated.  In  the  arrested  cases,  however,  these  become 
filled  in  with  Wormian  bones,  and  the  component  parts  of  the 
cranium  become  firmly  united.  The  scalp  is  thinned,  and  often 
marked  by  large  and  prominent  veins.  The  excessive  size  of  the 
cranium,  in  conjunction  with  the  smaU  face,  causes  the  head,  as 
seen  from  the  front,  to  have  a  very  characteristic  conformation, 
resembling  an  inverted  p3n:amid,  thereby  producing  a  curiously 
"top-heavy"  appearance.  The  circumference  varies  from  a 
little  above  the  normal  to  as  much  as  30  inches  or  more.  The 
average  measurement  of  the  chronic  cases  seen  in  institutions  is 
about  25  or  26  inches,  but  there  is  no  constant  relationship 
between  the  size  of  the  skull  and  the  degree  of  mental  impair- 
ment. The  prognosis  will  depend  upon  whether  the  disease  is 
stationary  or  slowly  progressing.  In  the  latter  dementia  is 
usually  the  ultimate  result. 

The  two  conditions  which  might  be  confounded  with  hydro- 
cephalus are  hypertrophic  amentia  and  rickets.  The  distinction 
in  regard  to  the  former  of  these  has  already  been  given.  In 
rickets  the  skull  is  often  enlarged,  but  such  is  due  to  a  thickening 
and  increased  density,   and  not  a  distension.     Moreover,   the 


238  Mental  Deficiency 

rickety  skull  is  usually  asymmetrical,  bossed,  and  ridged  ;  the 
fontanelle,  if  still  open,  is  depressed,  and  not  elevated  ;  there  is 
an  absence  of  the  thin  and  prominently  veined  scalp,  and  other 
signs  of  rickets  are  present. 

Illustrative  Cases. 

G.  P.,  male,  was  admitted  into  the  Littleton  Home  for  Defective 
Children  when  six  years  of  age.  He  was  an  orphan,  and  no 
history  bearing  upon  his  condition  was  obtainable.  He  was  a 
delicate-looking  boy  of  average  height,  with  a  typical  hydro-  | 
cephalic  skull,  the  circumference  of  which  was  22J  inches.  The 
palate  was  high  and  saddle-shaped,  the  teeth  irregular.  There 
was  left  internal  strabismus,  also  deficient  power,  but  no  definite 
paralysis,  of  the  left  arm  and  leg.  He  dragged  both  feet  in 
walking,  and  the  body  balance  was  poor.  He  knew  his  letters 
and  numbers,  and  could  spell  a  few  simple  words,  and  his  mental 
condition  generally  was  one  of  mild  defect.  Articulation  was 
good,  and  his  disposition  was  bright  and  cheerful.  There  was 
very  little  change  for  three  or  four  months,  although  the  boy  made 
no  headway  in  school.  He  then  began  to  be  silent  and  pensive, 
and  to  lose  interest  in  his  surroundings.  The  physical  signs  also 
increased,  the  legs  became  definitely  spastic,  so  that  walking 
was  impossible,  and  all  movements  were  performed  with  diffi- 
culty. By  the  end  of  six  months  the  cranium  had  increased 
J  inch  in  circumference,  and,  as  he  was  becoming  physically 
helpless  and  showing  signs  of  dementia,  I  was  compelled  to 
discharge  him. 

C.  H.,  male.  The  fifth  born  of  a  family  of  eight,  two  of  whom 
are  said  to  be  in  good  health,  although  one  is  a  heavy  drinker.  A 
third  is  ''  very  delicate,"  and  the  remainder  died  in  infancy  ; 
one  was  a  cripple.  The  father  died,  aged  fifty-two,  of  bron- 
chitis ;  the  mother  died,  aged  forty-seven,  of  general  paralysis. 
The  patient  seemed  all  right  at  birth,  but  had  a  **  fit  "  when  a 
year  old,  and  from  that  time  his  head  was  noticed  to  get  rapidly 
bigger.  He  did  not  walk  until  late,  and  then  very  badly,  and  he 
always  seemed  more  simple  and  childish  than  other  children. 
He  made  little  progress  at  school,  and  at  the  age  of  fourteen  was 
admitted  to  an  imbecile  institution.  He  remained  there  for  two  '• 
years,  but,  becoming  destructive  and  violent,  he  was  transferred  \ 


Secondary  Amentia  and  its  Clinical  Varieties  239 

to  an  asylum.  He  was  a  pronounced  hydrocephalic,  in  poor 
physical  condition,  but  clean  in  his  habits  ;  able  to  converse,  and 
capable  of  helping  a  little  in  the  wards.  The  head  increased  in 
size,  and  he  gradually  became  more  helpless.  He  is  now  eighteen 
years  of  age,  and  has  been  bedridden  for  over  a  year.  His  con- 
dition is  as  follows  :  The  skull  is  typically  hydrocephalic,  and 
measures  25  inches  in  circumference.  There  is  spastic  paresis 
of  both  legs  from  the  thighs  downwards  ;  he  can  just  stand,  but 
is  quite  unable  to  walk.  The  arms  do  not  appear  to  be  affected. 
The  knee-jerks  are  increased,  and  double  ankle  clonus  is  present  ; 
also  Babinsky's  toe  sign.  On  making  movements  a  marked 
clonus  of  the  legs  appears,  but  there  are  no  convulsions.  He  can 
hear  and  see,  but  is  of  decidedly  defective  understanding.  As  a 
rule,  when  questioned,  he  gazes  at  one  in  a  stolid,  helpless  way, 
and  makes  no  attempt  to  reply  ;  when  he  does  speak,  his  words 
are  unintelligible.  He  pulls  to  pieces  everything  which  comes 
into  his  hands,  but  takes  practically  no  notice  of  persons  or  things 
round  him.     It  is  obvious  that  the  disease  is  rapidly  progressing. 

/.  T.,  male.  The  fourth  of  a  family  of  five,  of  whom  one  died 
in  infancy  ;  the  others  are  alive  and  well.  There  is  insanity  on 
the  father's  side,  and  consumption  on  the  mother's.  The 
patient  was  born  with  a  very  big  head,  labour  being  much 
prolonged.  He  did  not  walk  until  turned  four  years,  and  has 
always  been  clumsy  in  his  movements.  He  was  a  little  back- 
ward at  school,  but  no  marked  mental  abnormality  was  noticed 
until  the  age  of  ten,  when  he  began  to  get  passionate  and  difficult 
to  control.  He  showed  a  remarkable  memory  for  ages,  and  his 
mother  says  that  he  knew  the  age  of  every  one  of  their  numerous 
relations. 

He  left  school  aged  fourteen,  and  was  put  to  bootmaking  ;  but 
he  never  did  much  good,  and  after  a  short  time  he  was  taken 
away.  He  remained  at  home  pottering  about,  but  doing  no 
work,  until  thirty-four  years  of  age.  A  change  then  came  over 
him  ;  he  began  to  wander  about  at  night,  and  sometimes  stayed 
away  from  home  for  several  days  together.  He  would  put 
tobacco  into  the  teapot,  and  do  similar  foolish  things.  He 
became  rambling  in  his  conversation,  and  said  that  "  Jack  the 
Ripper  "  had  tried  to  cut  his  throat.  He  refused  his  food, 
saying   that   it   had   been   drugged.      Finally   he   attacked   his 


240  Mental  Deficiency 

mother  with  a  knife,  and  became  so  maniacal  that  he  had  to  be 
sent  to  an  asylum. 

On  admission  he  had  a  typical  hydrocephalic  head,  convergent 
strabismus,  and  slight  dragging  of  the  left  leg.  He  was  loquacious, 
but  of  decidedly  feeble  intellect.  The  maniacal  condition  passed 
off,  and  he  became  quiet  and  well-behaved,  and  he  remained  in 
this  condition  for  several  years,  subject,  however,  to  delusions 
that  some  unknown  persons  put  poison  into  his  food.  Then  the 
legs  became  weaker,  so  that  he  was  unable  to  get  about,  and 
now,  at  the  age  of  forty-five  years,  he  is  bedridden.  There  is 
well-marked  spastic  paraplegia,  so  that  he  is  unable  to  walk,  or 
even  stand,  without  support.  The  arms  are  unaffected.  The 
knee-jerks  are  increased,  and  Babinsky's  sign  is  present  on  the 
right  side.  Both  legs  and  feet  are  blue  and  cold.  There  is  no 
diminution  in  tactile  sensation  over  any  part  of  the  body,  and 
his  power  of  localizing  touch  is  remarkably  good.  He  frequently 
complains  of  a  girdle  sensation  round  the  epigastrium.  There  is 
fine  tremor  of  the  hands  on  extension,  and  of  the  legs  on  attempt- 
ing movement,  but  no  convulsions  of  any  kind.  The  special 
senses  are  normal.  Articulation  is  slightly  defective,  but  speech 
is  coherent  and  rational.  Memory  is  very  good  indeed.  He 
notices  all  that  goes  on  round  him,  and  can  give  a  very  good 
account  of  his  past  life,  but  his  ideas  are  childish  and  his  judg- 
ment and  reasoning  defective.  He  can  read,  write,  and  do  sums 
remarkably  well.  He  has  lately  developed  incontinence.  The 
cranial  circumference  is  25  J  inches. 


SYPHILITIC  AMENTIA. 

It  is  a  somewhat  remarkable  fact  that,  although  syphilis  is  a 
frequent  cause  of  disease  in  the  fully  developed  brain,  and 
although  so-called  inherited  (really  acquired  in  utero)  syphilis 
is  exceedingly  common,  yet  the  number  of  cases  of  amentia  due 
to  this  cause  is  quite  insignificant.  They  probably  do  not  com- 
prise at  most  more  thaTrTf-«tc..2_p.er'-<:ent.  of  all  aments.  One  is 
driven  to  the  conclusion  that  syphilis  is  a  much  more  potent 
agent  in  producing  neuronic  degeneration  than  arrest,  and  this 
view  is  confirmed  by  the  subsequent  history  of  many  aments 
who  owe  their  deficiency  to  this  cause.     Further,  in  most  of 


Secondary  Amentia  and  its  Clinical  Varieties    241 

these  cases  in  which  syphilis  is  a  factor  there  are  other  influences, 
generally  neuropathic  heredity,  and  it  would  seem  as  if  the 
specific  virus  were  chiefly  productive  of  harm  upon  the  nervous 
system  in  the  presence  of  a  neuropathic  or  psychopathic  diathesis. 
In  my  own  series  of  cases  the  number  of  aments  whose  condition 
was  the  result  of  syphilis  alone  (without  neuropathic  heredity) 
was  but  0'5  per  cent.  It  is  interesting  to  note  that  the  same 
applies  also  to  degenerations  of  the  brain  and  spinal  cord 
occurring  in  later  life.  General  paralysis,  of  which  syphilis  is 
the  predominant  exciting  cause,  has  been  shown  to  be  accom- 
panied by  morbid  neuropathic  heredity  in  a  large  proportion  of 
cases  ;  and  Mott  has  shown  that  the  site  of  incidence  of  the  poison 
upon  the  spinal  cord  is  often  determined  by  antecedent  localized 
stress  and  strain  producing  a  locus  minoris  resistenticB. 

There  are  several  ways  in  which  the  poison  of  syphilis  may  con- 
ceivably determine  amentia — one,  by  producing  such  a  general 
disturbance  of  nutrition  as  to  arrest  neuronic  growth,  this  I 
believe  to  be  exceedingly  rare  ;  another,  and  in  my  opinion  the 
usual  modus  operandi,  by  directly  poisoning  and  so  checking 
the  growth  of  the  developing  cortical  cells.  It  has  been  stated 
by  some  writers  that  syphilis  can  only  produce  amentia  by 
causing  gross  lesions  of  the  skuU,  membranes,  or  brain.  Possibly 
some  cases  of  hydrocephalic  amentia  are  of  this  nature,  but  I 
do  not  think  that  this  result  is  common.  It  is  true  that  in  a 
considerable  proportion  of  cases  the  defective  neurones  subse- 
quently undergo  degeneration,  and  that  considerable  wasting  of 
the  brain  ensues  ;  but  even  this  is  not  accompanied  by  the 
ordinary  syphilitic  lesions,  and  I  think  that  in  most  cases 
amentia,  in  the  first  instance,  results  from  the  growth  of  the 
neurones  being  interfered  with  by  a  syphilitic  toxaemia. 

In  addition  to  this,  syphilis  may,  of  course,  produce  amentia 
indirectly  by  bringing  about  a  devitalization  of  the  germ  plasm, 
as  we  have  already  mentioned  in  treating  of  causation.  But 
such  cases  hardly  come  within  the  category  of  syphilitic  amentia, 
for  this  action  of  the  poison  is  hereditary,  and  such  cases  are 
primary,  not  secondary  amentia.  The  specific  signs  of  syphilis 
are  absent,  and  the  condition  is  in  reality  what  has  been  described 
by  Fournier  as  "  paras yphilitic." 

In  cases  of  secondary  amentia  directly  due  to,  or  determined 

16 


242  Mental  Deficiency 

by,  syphilis,  which  are  the  only  ones  to  which  we  shall  apply 
the  term  ''syphilitic  amentia,"  the  usual  symptoms  of  inherited 
syphilis  are  present  in  infancy,  and  their  characteristic  lesions — 
— viz.,  keratitis,  Hutchinson's  teeth,  scars,  depressed  nose,  etc. — 
are  generally  found  in  after-life.  In  addition,  the  body  is  usually 
stunted  and  ill-formed,  the  child  is  backward  in  walking  and 
talking  (one  of  my  cases  did  not  speak  at  all  until  the  ninth  year), 
and  some  amount  of  mental- deficiency  is  usually  apparent  in  the 
first  few  years  of  life.  As  a  rule,  this  is  of  a  comparatively  mild 
degree,  most  of  the  cases  being  merely  feeble-minded  or  high- 
grade  imbeciles.  They  go  to  school,  but  make  no  progress,  and 
upon  leaving  they  are  found  incapable  of  following  any  constant 
employment.  Occasionally  the  mental  status  is  that  of  idiocy ; 
but  up  to  the  age  of  twelve  to  fifteen  years  the  syphilitic  ament, 
beyond  the  presence  of  the  typical  lesions,  presents  no  special 
mental  peculiarities  which  distinguish  him  from  an  ordinary 
ament  of  similar  degree. 

About  or  shortly  after  the  usual  age  of  puberty,  however,  a 
considerable  number  of  these  persons  undergo  a  remarkable 
change.  It  is  noticed  that  the  patient  is  becoming  restless  and 
troublesome.  Hallucinations  and  delusions  often  make  their 
appearance,  and  in  some  cases  there  is  pronounced  mania  or 
melancholia.  Soon  after  this  the  balance  and  gait  of  the  body 
become  markedly  unsteady,  there  is  considerable  tremor  of  the 
hands,  mouth,  and  tongue,  and  the  speech  becomes  slurred,  in- 
distinct, and  hesitating.  The  knee-jerks  are  increased,  and  ankle 
clonus  is  often  found.  Sight  and  hearing  are  impaired,  and  if 
the  eyes  be  examined  the  pupils  will  be  seen  to  be  dilated  and 
to  react  sluggishly  to  light ;  at  a  later  stage  they  become  fixed. 
These  changes  are  followed  by  a  marked  mental  impairment, 
and  the  youth  ceases  to  take  any  interest  in  his  surroundings. 
There  is  no  remission,  and  time  only  results  in  an  aggravation 
of  all  these  symptoms.  The  body  begins  to  waste,  swallowing 
becomes  difficult,  and  the  patient  gets  dirty  in  his  habits.  With 
the  emaciation  there  is  often  considerable  trophic  disturbance, 
so  that  sores  appear.  Finally  he  becomes  bedridden,  gradually 
sinks  into  a  comatose  state,  and  dies.  In  males  the  external 
genitals  retain  their  infantile  condition,  and  in  females  men- 
struation does  not  appear.     I  have  never  noticed  any  grandiose 


Secondary  Amentia  and  its  Clinical  Varieties     243 

ideas  in  these  persons  ;  but  convulsive  seizures  are  common,  and 
these  are  occasionally  followed  by  transient  paralysis.  The 
average  length  of  time  from  the  onset  of  these  symptoms  to  the 
end  is  about  five  years. 

It  is  seen  that  the  symptoms  and  course  of  this  progressive 
degeneration  are  practically  identical  with  those  of  juvenile 
general  paralysis,  and  this  is  further  shown  by  the  post-mortem 
appearances.  In  four  cases  which  I  have  examined  post-mortem 
the  brain  was  small  and  simply  convoluted  as  well  as  wasted, 
the  pia-arachnoid  thickened  and  opaque,  and  the  cerebro-spinal 
fluid  in  considerable  excess.  There  were,  however,  no  gross 
syphilitic  lesions.  Microscopical  examination  showed  many  ceUs 
in  a  typical  condition  of  incomplete  development,  but  over  and 
beyond  this  there  were  extensive  degenerative  changes  indis- 
tinguishable from  those  occurring  in  general  paralysis.* 

I  do  not  think  that  this  is  the  termination  of  every  case  of 
syphilitic  amentia,  for  I  have  seen  a  few  of  these  patients  who, 
at  over  thirty  years  of  age,  showed  no  mental  or  physical  altera- 
tion apart  from  the  original  deficiency.  But  although  I  have 
made  diligent  search,  these  latter  cases  are  comparatively  rare, 
and  I  am  inclined  to  think  that  progressive  deterioration,  ending 
in  paralytic  dementia,  is  the  rule  in  amentia  due  to  syphilis. 

The  Diagnosis  of  syphilitic  amentia  rests  upon  the  presence  of 
the  typical  lesions,  plus  amentia,  in  the  patient.  In  one  of  my 
cases  the  signs  were  indefinite,  but  the  patient's  mother  had  died 
of  general  paralysis.  In  another  case  a  history  was  present,  but 
no  marks  could  be  discovered  upon  the  patient ;  a  brother,  how- 
ever, presented  the  characteristic  signs.  Both  these  cases  were  con- 
sidered to  be  probably  syphilitic,  and  they  subsequently  developed 
general  paralysis.  Diagnosis  at  times,  therefore,  must  be  a 
matter  of  uncertainty.  The  remaining  cases  showed  the  charac- 
teristic lesions.  It  need  hardly  be  emphasized  that  all  subjects  of 
congenital  syphilis  do  not  suffer  from  mental  deficiency ;  on  the 
contrary,  the  proportion  who  become  aments  is  exceedingly 
small.     It  is   probable  that  in  most  of  these  cases  the  arrest 

*  For  one  of  the  best  accounts  of  the  histology  of  juvenile  general 
paralysis,  as  shown  by  modern  methods  of  staining,  see  that  by  Watson 
in  Mott's  "  Archives  of  Neurology,"  vol.  ii.,  p.  621.  Three,  at  least,  of 
the  twelve  cases  there  recorded  were  aments. 

16 — 2 


244  Mental  Deficiency 

of  mental  development  is  as  much  a  consequence  of  morbid 
heredity  as  of  the  syphilitic  virus,  since  such  heredity,  or  some 
potent  predisposing  cause,  is  present  in  the  majority  of  cases. 
Given  a  child  with  congenital  syphilis,  who  is  at  the  same  time 
the  offspring  of  a  neuropathic  or  degenerate  stock,  then  I  think 
that  amentia  is  extremely  likely  to  result. 

It  has  been  stated  by  Hirsch  that  all  individuals  suffering  from 
juvenile  general  paralysis  have  previously  been  of  feeble  intellect. 
With  this,  however,  I  cannot  agree,  as  I  have  known  several  such 
patients  whose  mental  condition  had  been  quite  up  to  the  normal 
prior  to  the  onset  of  the  degenerative  changes.  But  juvenile 
general  paralytics  who  are  seen  in  the  consulting-room  or  asylum 
in  the  early  stages  of  their  disease  are  often  thought  to  be 
imbeciles.  Inquiries  as  to  the  previous  mental  status  will  readily 
distinguish  between  the  two  conditions. 

Prognosis. — In  view  of  the  liability  of  these  patients  to  develop 
general  paralysis,  it  is  obvious  that  a  most  guarded  opinion  must 
be  given  regarding  the  ultimate  prospects  of  improvement  from 
training,  in  any  case  of  amentia  which  is  considered  to  be  syphi- 
litic. Progressive  dementia  does  not  always  result,  but  it  does 
certainly  appear  to  be  extremely  common  ;  and  antisyphilitic 
treatment  has  been  found  to  have  not  the  slightest  effect  upon 
either  the  degeneration  or  the  initial  mental  deficiency. 


Illustrative  Cases. 

Syphilitic  Amentia  terminating  in  General  Paralysis. — M.  D.,  " 
female,  the  sixth  of  a  family  of  ten.  The  fifth  died  of  "  water 
on  the  brain  "  in  infancy,  and  the  seventh  and  eighth  were  mis- 
carriages. The  remainder  are  said  to  be  "  all  right."  There  is 
phthisis  on  the  mother's  side,  but  no  insanity  discoverable.  The 
patient  was  decidedly  backward  at  school ;  afterwards  she 
stayed  at  home  to  help  her  mother,  as  she  did  not  seem  equal  to 
taking  a  place.  At  the  age  of  nineteen  years  she  began  to  get 
mischievous  and  destructive,  and  finally  became  so  troublesome 
that  she  had  to  be  sent  to  an  asylum.  On  admission  in 
October,  1899,  she  was  described  as  being  of  very  poor  intelli- 
gence, wet  and  dirty  in  habits,  noisy  day  and  night,  talking 
incessantly  and  using  disgusting  language  without  any  con- 
nexion   of    ideas.     Her    condition    was    such    that    systematic 


I 


i 


Secondary  Amentia  and  its  Clinical  Varieties     245 

examination  was  impossible.  She  gradually  became  somewhat 
quieter,  and  when  seen  by  me,  nine  months  after  admission,  her 
condition  was  as  follows  :  A  lethargic,  almost  stuporose,  girl  who 
spent  the  whole  day  sitting  in  a  chair,  indifferent  to  anything 
happening  round  her.  She  understood  what  was  said  to  her,  but 
was  unable  to  carry  on  conversation  or  to  answer  simple  questions 
properly.  Speech  slurred  and  tremulous.  She  attempted  to 
write  at  my  request,  but  her  hand  was  so  tremulous  that  it  was 
impossible  to  do  so.  Knee-jerks  greatly  exaggerated ;  ex- 
tremities blue  and  cold.  No  paresis  ;  no  seizures.  Well-marked 
signs  of  rickets  and  congenital  syphilis.  I  diagnosed  syphiUtic 
amentia,  with  beginning  general  paralysis,  but  was  unable  to 
see  the  patient  again,  and  had  forgotten  entirely  about  her  until 
going  through  my  notes.  The  medical  superintendent  was  good 
enough  to  supply  me  with  the  subsequent  history,  from  which 
it  appeared  that  unmistakable  signs  of  general  paralysis  appeared 
towards  the  end  of  igoi ;  that  phthisis  was  observed  in  February, 
1902  ;  and  that  she  died  on  March  29  of  the  same  year.  Her 
age  at  death  was  twenty-three  years,  and  the  cause,  as  ascer- 
tained post-mortem,  was  general  paralysis  and  phthisis. 

Syphilitic  Amentia  terminating  in  General  Paralysis.  — 
T.  C,  male.  Father  alcoholic  and  insane  ;  his  mother  and  all 
his  brothers  and  sisters  alcoholic.  The  patient  is  the  second  of  a 
family  of  eight  ;  the  first-born  died  aged  two  and  a  half  months, 
and  the  mother  was  told  by  the  doctor  that,  had  it  lived.  "  it 
would  have  been  blind  and  an  idiot."  The  fourth  child,  whom 
I  have  seen,  has  marks  of  congenital  syphilis.  The  patient  was 
backward  in  walking  and  talking  ;  his  mother  says  he  could 
never  "  get  his  words  out  properly."  He  went  to  school,  but 
could  never  learn,  and  the  schoolmaster  said  he  was  "  a  regular 
fool."  He  subsequently  had  several  situations,  but  no  one  would 
keep  him  very  long.  At  fifteen  years  of  age  he  began  to  get  very 
bad-tempered  and  strange  in  his  manner ;  he  had  attacks  of 
screaming,  which  lasted  for  hours ;  and  ultimately,  at  seventeen 
years,  was  sent  to  an  asylum  with  acute  mania.  This  gradually 
subsided,  revealing  a  condition  of  mild  imbecility  with  beginning 
dementia.  When  asked  his  name  and  age,  he  would  plaintively 
reply:  "I  ain't  got  no  name"  and  **  I  ain't  got  no  age."  The 
dementia  progressed  and  became  extreme,  and  he  died,  aged 
nineteen,  of  exhaustion  following  a  bout  of  seizures. 


246  Mental  Deficiency 

The  post-mortem  examination  revealed  a  simply  convoluted 
brain,  weighing  1,167  grammes,  and  having  the  characteristic 
appearances  of  general  paralysis.  The  microscope  showed  a 
condition  of  imperfect  cellular  development,  plus  subacute 
degeneration,  similar  to  that  occurring  in  general  paralysis. 

Syphilitic  Amentia  passing  into  Dementia  (probably  General 
Paralysis). — A.  A.,  male.  Morbid  heredity  on  paternal  side, 
but  no  history  of  syphilis  obtainable,  although  the  patient  has 
several  characteristic  syphilitic  lesions.  He  was  noticed  to  be 
backward  from  birth,  and  did  not  talk  until  eight  years  old. 
Went  to  school,  but  could  never  learn,  and  when  he  left,  at  the 
age  of  twelve,  he  was  only  in  the  second  standard.  He  had  fits 
between  six  and  seven  years  of  age,  which  continued  occasionally 
until  fourteen  years,  and  then  ceased.  No  employment.  Became 
unmanageable,  and  was  sent  to  an  imbecile  institution  when  aged 
seventeen.  Remained  there  for  two  years,  but  made  no  progress, 
and  was  transferred  to  an  asylum.  He  gradually  became  paretic 
and  tremulous,  with  small  pupils,  which  scarcely  reacted  to  light. 
AtTthe  present  time  (aged  twenty)  he  is  very  simple,  and  answers 
questions  in  a  slow,  monotonous,  and  trembling  manner.  He 
cannot  do  the  simplest  sums,  and  does  not  know  how  many 
pennies  there  are  in  sixpence.  There  is  undoubtedly  con- 
siderable mental  deterioration  in  addition  to  the  original  defect, 
and  it  is  probable  that  general  paralysis  is  supervening. 

Syphilitic  Amentia  terminating  in  General  Paralysis. — L.  B., 
female.  Was  admitted  into  the  asylum  at  the  age  of  fifteen,  the 
certificate  stating  :  "  She  sits  apparently  dazed,  taking  no  iijterest 
in  anything  that  is  going  on.  Threatened  to  kill  herself.  Tears 
her  clothing,  and  at  times  cries  land  stamps  her  feet."  The  history 
is  incomplete,  but  it  was  elicited  that  the  patient  had  been  dull 
and  of  defective  eyesight  since  birth  ;  that  her  mother  died,  aged 
forty-two,  of  general  paralysis  ;  and  that  her  father  was  alive, 
and  said  to  be  in  good  health.  Though  intellectually  dull,  she 
was  said  to  have  been  cheerful  until  the  last  six  months,  since 
when  she  had  become  stubborn  and  morose,  finally  helpless, 
dirty  in  her  habits,  and  quite  unable  to  look  after  herself. 

On  admission  the  pupils  were  dilated,  the  reaction  to  light 
sluggish,  and  her  memory  for  time  and  events  much  impaired. 
She  was  gloomy  and  apathetic,  and  had  delusions,  such  as  that 
ferocious  dogs  were  coming  after  her.     There  was  left  external 


Plate  XX. 


To /ace  page  246.] 


OF  y 


Secondary  Amentia  and  its  Clinical  Varieties     247 

strabismus,  but  no  other  observable  paresis  and  no  convulsions. 
The  knee-jerks  were  exaggerated.  Marks  of  congenital  syphilis 
were  present.  Cranial  circumference,  2if  inches.  She  was  con- 
sidered to  be  a  case  of  syphilitic  amentia  with  superadded  dementia. 
The  dementia  steadily  increased,  and  the  patient  died  at  the  age 
of  eighteen  years,  of  broncho-pneumonia. 

On  making  a  post-mortem  examination,  I  found  the  brain  to 
be  of  fair  size  (1,176  grammes),  but  somewhat  simply  convoluted. 
The  optic  nerves  were  exceedingly  small.  The  brain  and  mem- 
branes had  the  characteristic  naked-eye  appearances  of  general 
paralysis.  A  microscopical  examination  of  various  regions  of  the 
cortex  cerebri  revealed  a  marked  numerical  deficiency  of  the  cells  ; 
many  of  them  were  also  of  incomplete  development  and  irregular 
arrangement.  These  indications  of  imperfect  development  were 
most  pronounced  in  the  small  and  medium-sized  pyramidal  cells 
of  the  frontal  lobes.  In  addition,  there  was  a  considerable 
amount  of  chronic  and  subacute  degeneration,  with  proliferation 
of  neuroglia  identical  with  that  occurring  in  general  paralysis. 

Syphilitic  Amentia  with  Progressive  Dementia. — S.  G.,  male. 
No  relatives  living,  and  no  history  or  particulars  ascertainable 
beyond  the  fact  that  he  had  lived  in  imbecile  institutions  since 
the  age  of  nine  years.  In  January,  1895,  at  the  age  of  nineteen 
years,  he  became  violent  and  unmanageable,  attacked  the  atten- 
dants, and  threatened  to  cut  his  throat ;  he  was  accordingly 
transferred  to  a  lunatic  asylum.  On  admission  he  was  found 
to  be  an  imbecile  with  aural  hallucinations  and  mild  mania.  He 
said  that  voices  spoke  to  him  and  told  him  to  cut  his  throat. 
Many  typicsd  marks  of  congenital  syphilis  were  present,  and  he 
had  a  habit  of  constantly  keeping  his  mouth  tightly  closed 
in  a  fatuous  grin,  at  the  same  time  breathing  noisily  through 
his  nose.  (See  Plate  XX.,  Fig.  49.)  He  remained  in  practi- 
cally the  same  condition  for  the  next  five  years,  at  times 
being  depressed  and  lachrymose,  at  others  nois}/  and  trouble- 
some; he  was,  however,  clean  in  habits,  and  was  capable  of 
doing  everything  for  himself.  In  December,  1900,  at  the  age 
of  twenty-four  years,  he  began  to  show  signs  of  dementia, 
becoming  stolid  and  indifferent  to  his  surroundings,  and  fre- 
quently wet  and  dirty.  The  knee-j  erks  were  greatly  exaggerated. 
The  dementia  gradually  became  more  marked,  his  gait  became 
shuffling  and  unsteady,  and  the  knee-jerks  could  not  be  obtained. 


248  Mental  Deficiency 

During  the  year  1902  he  began  to  show  marked  bodily  enfeeble- 
ment,  the  dementia  still  continuing  to  progress.  In  February, 
1904,  pulmonary  tuberculosis  was  diagnosed  ;  it  advanced  with 
great  rapidity,  and  he  died  the  following  month  at  the  age  of 
twenty-eight  years.  There  had  never  been  convulsions  or 
seizures.  Post-mortem  examination  revealed  a  wasted  brain 
presenting  the  usual  features  of  chronic  dementia,  but  none  of 
the  particular  signs  of  general  paralysis.  Its  weight  was  1,100 
grammes.     There  was  extensive  tuberculosis  of  both  lungs. 

Syphilitic  Amentia  passing  into  Dementia.''^ — Family  History. — 
The  father  has  had  syphilis ;  a  brother  of  the  patient  also  has 
"  tremblings  "  ;  no  further  details  obtainable. 

Clinical. — The  patient  was  always  a  quiet  lad,  and  did  not 
seem  so  bright  as  the  other  children.  At  the  age  of  six  years  he 
began  to  show  definite  ataxic  symptoms  (said  to  have  been 
caused  by  a  fright),  chiefly  marked  in  the  legs.  There  was  no 
actual  loss  of  power  complained  of,  but  he  was  only  able  to 
stand  with  the  feet  apart,  and  was  very  unsteady  and  apt  to  fall 
whilst  walking  ;  the  knee-jerks  were  absent  on  both  sides,  the 
pupils  were  widely  dilated,  considerable  tremor  of  the  eyelids  was 
present,  and  there  was  occasional  incontinence  of  urine.  The 
patient  gradually  became  worse,  eventually  becoming  almost 
completely  powerless  and  helpless  in  bed,  and  quite  demented  : 
he  died  at  the  age  of  eight  years. 

Upon  making  a  microscopical  examination,  I  found  imperfect 
development  and  irregular  arrangement  of  the'small  and  medium- 
sized  pyramidal  cells  of  the  cerebral  cortex,  indicating  a  condition 
of  mild  imbecility.  In  addition  there  was  a  subacute  degenera- 
tion affecting  a  large  number  of  these  cells,  and  to  a  less  extent 
those  of  the  anterior  horns  of  the  spinal  cord  ;  there  was  also  a 
somewhat  more  chronic  degeneration  of  the  cells  and  fibres  of  the 
pyramidal  tract,  and  the  vessel  walls  generally  were  slightly  thick- 
ened. I  did  not  see  this  case  during  life,  but  there  are  many 
points  in  both  the  clinical  and  pathological  appearances  which 
suggest  that  this  degenerative  process  which  was  superadded  to 
the  mild  amentia  was  analogous  to,  if  not  identical  with,  that  of 
juvenile  general  paralysis. 

*  For  the  clinical  notes  and  the  central  nervous  system  of  this  case 
I  am  indebted  to  Dr.  F.  J.  Smith,  Physician  to  the  London  Hospital. 


Secondary  Amentia  and  its  Clinical  Varieties     249 


AMAUROTIC  FAMILY  IDIOCY,  OR  INFANTILE  CEREBRAL 
DEGENERATION. 

This  disease  is  invariably  fatal,  and  its  subjects  never  survive 
sufficiently  long  to  become  candidates  for  a  special  institution  for 
the  mentally  deficient ;  but  as  it  is  one  in  which  arrested  cerebral 
development  is  a  prominent,  although  incidental,  feature,  and  as 
on  this  account  it  might  be  confounded  with  the  more  ordinary 
forms  of  amentia,  it  is  necessary  to  allude  to  it. 

The  earliest  account  we  have  is  that  given  by  Mr.  Waren  Tay 
in  1881,  whose  description  chiefly  referred  to  the  peculiar  ocular 
conditions.  In  1887  Dr.  B.  Sachs,  of  New  York,  described  the 
changes  in  the  brain  in  a  paper  entitled  "  Arrested  Cerebral  De- 
velopment." Other  descriptions  have  been  given  by  Goldzicher, 
Magnus,  Knapp,Wadsworth,  Hirschberg,  Carter,  Hirsch,  Petersen, 
and  Burnet.  The  most  complete  account,  however,  is  that  of 
Kingdon  and  Risien  Russell,*  which  appeared  in  1897,  and  it  is 
upon  this  that  the  description  here  given  is  chiefly  based. 

Infantile  cerebral  degeneration  is  a  disease  which  usually 
attacks  more  than  one  child  of  the  same  family,  and  all  the  cases 
hitherto  recorded  have  occurred  in  Jews.  Male  and  female  chil- 
dren are  equally  liable  to  be  affected,  but  no  particular  exciting 
or  predisposing  factor  has  yet  been  discovered.  There  is  no 
regularity  in  the  order  in  which  children  of  the  same  family  are 
affected.  It  may  be  the  earlier,  later,  or  intermediate  children, 
the  rest  remaining  perfectly  healthy.  Kingdon  and  Russell 
describe  the  symptoms  and  progress  of  the  disease  in  three  stages 
as  follows  : 

First  Stage. — An  infant,  the  subject  of  this  disease,  is  born  at 
the  full  time  of  gestation,  and  may  be  well  formed  and  developed, 
differing  in  no  outward  respect  from  a  healthy  child,  until  about 
the  completion  of  the  third  month-  At  this  time  some  weakness 
of  the  muscles  of  the  back  and  neck  is  observed,  and  often  a  sus- 
picion that  the  child  sees  imperfectly  is  entertained.  Should  the 
eyes  be  examined  with  the  ophthalmoscope  about  the  fourth  or 

*  E.  C.  Kingdon  and  J.  S.  Risien  Russell,  "  Infantile  Cerebral  Degenera- 
tion," Medico-Chirurgical  Transactions,  vol.  Ixxx.,  1897.  This  paper 
gives  a  full  account  of  the  clinical  and  pathological  conditions,  together 
with  a  bibliography  of  the  subject. 


250  Mental  Deficiency 

fifth  month,  there  will  be  found  symmetrical  changes  in  the  macula 
lutea,  consisting  of  a  whitish-grey  patch,  somewhat  oval  in  shape 
(the  axis  being  horizontal),  with  softened  edges  slightly  raised 
above  the  general  surface  of  the  retina.  In  the  centre  of  this 
patch  is  seen  the  fovea  centralis  as  a  dark  cjiernMred  s£ot.  These 
changes  in  the  maculae  remain  unaltered,  and  are  regarded  as 
absolutely  pathognomonic.  At  a  somewhat  later  course  of  the 
disease  there  is  definite  optic  atrophy  and  total  amaurosis. 

In  the  Second  Stage  the  child  is  unable  to  sit  up  ;  its  head 
falls  backwards  if  unsupported  ;  when  lying  on  its  back  it  is  un- 
able to  turn  over  to  either  side.  Objects  placed  in  its  hands  are 
grasped  but  feebly,  and  soon  dropped.  It  is  generally  apathetic, 
taking  no  notice  of  surrounding  objects,  and  the  face  bears  an 
expression  of  mental  enfeeblement.  Vision  is  reduced  to  per- 
ception of  light,  but  the  sense  of  hearing  is  acute,  and  remains  so 
during  life,  any  sudden  sound  causing  the  child  to  start.  The 
sense  of  taste  is  also  preserved. 

In  the  Third  Stage  atrophy  of  the  enfeebled  muscles  ensues, 
and  soon  those  of  the  whole  body  are  involved.  Emaciation  pro- 
gresses, and  becomes  most  marked.  The  deep  reflexes  are  exag- 
gerated, and  still  later  in  the  course  of  the  disease  rigidity  of  the 
extremities  and  retraction  of  the  head  become  prominent 
features  ;  occasional  spasmodic  contractions  cause  the  child  to 
start  and  cry  from  pain.  Convulsions  have  been  noted  in  one  or 
two  instances  during  the  course  of  the  disease,  but  they  would 
appear  to  be  an  accidental  accompaniment,  and  are,  at  all  events, 
not  the  rule.  The  temperature  remains  normal  throughout  the 
course  of  the  disease.  The  heart,  lungs,  and  abdominal  viscera 
are  also  normal. 

The  duration  of  life  varies  from  one  and  a  half  to  two  and  a 
half  years,  but  is  usually  less  than  two  years.  All  the  subjects  of 
this  disease  are  known  to  have  died  except  two,  and  they  were 
becoming  worse  when  last  seen. 

The  essential  pathological  lesion  would  appear  to  be  a  primary 
degeneration  of  the  cortical  neurones,  the  optic  nerves,  and  the 
pyramidal  tracts  throughout  their  whole  course  in  the  pons, 
medulla,  and  spinal  cord.  The  nature  of  the  lesions  and  the 
general  clinical  course  would  suggest  that  the  cause  is  some  circu- 
lating toxine,  but  hitherto  none  such  has  been  discovered. 


Secondary  Amentia  and  its  Clinical  Varieties     251 

Section  II. 

AMENTIA  DUE  TO  DEFECTIVE  CEREBRAL  NUTRITION. 

Mental  growth  takes  place  as  a  result  of  two  factors.  First, 
the  embryonic  neuroblasts  must  have  within  them  a  capacity  for 
developing  and  acquiring  certain  functional  connexions.  Secondly , 
they  must  be  supplied  with  food  adequate  in  quantity  and  quality, 
and  they  must  also  be  stimulated  by  impressions  from  without 
reaching  them  through  the  avenues  of  special  sense.  If  either  of 
these  latter  essentials  to  growth  be  absent  or  diminished,  mental 
development  may  be  so  interfered  with  that  a  condition  of 
amentia  results,  and  this  is  conveniently  termed  '*  amentia  due 
to  defective  cerebral  nutrition."  Of  the  type  which  is  due  to 
quantitative  or  qualitative  changes  in  the  blood,  cretinism  is  the 
best,  as  well  as  most  common,  example.  The  variety  due  to 
defective  stimulation  is  known  as  ''  amentia  due  to  isolation  or 
sense  deprivation." 

CRETINISM. 

Although  cretins  have  been  recognized  and  remarked  upon  for 
hundreds  of  years  (even  by  such  ancient  writers  as  Juvenal,  Pliny, 
Strabo,  as  well  as  by  the  more  modern  Paracelsus),  it  is  only 
comparatively  recently  that  the  cause  of  this  condition  has  been 
at  all  understood.  It  is  now  established  beyond  doubt  that 
cretinism  is  closely  allied  to  myxoedema,  and  that  they  are  both 
dependent  upon  an  absence  or  diminished  secretion  of  the  thyroid 
gland. 

There  are  two  kinds  of  cretinism — endemic  and  sporadic  ;  and 
although  these  have  much  in  common,  there  are,  nevertheless, 
important  points  of  difference  between  them  which  make  it 
necessary  to  consider  them  separately. 

Endemic  Cretinism. — Endemic  cretinism  is  a  disease  of  wide 
incidence.  It  is  most  common  in  Europe,  particularly  in  the 
mountains  and  valleys  of  Switzerland  and  the  adjacent  countries  ; 
but  it  also  occurs  in  the  Himalayas  of  India,  the  Andes  and 
Rocky  Mountains  of  America,  as  well  as  in  Burmah  and  Mada- 
gascar.    In  fact,  there  is  hardly  any  quarter  of  the  globe  which 


252  Mental  Deficiency 

is  free  from  this  affection.  In  England  cases  are  occasionally 
seen  in  Derbyshire  and  the  western  portion  of  Yorkshire.  In 
Somersetshire  it  used  to  be  fairly  common,  but  is  not  now  so 
frequently  seen.  In  practically  all  cases  of  the  endemic  form  of 
this  disease  a  goitre  is  present,  but  although  some  diversity  exists 
in  the  mental  and  bodily  condition  of  the  patients,  the  effect  on 
the  whole  seems  to  be  the  result  of  an  inadequate  and  not  exces- 
sive secretion  of  the  thyroid  gland. 

As  to  the  cause  of  this  thyroid  anomaly  we  know  very  little, 
but  it  seems  to  be  related  in  some  peculiar  manner  with  the 
water-supply.  It  is  probable  that  the  future  will  reveal  the 
presence  of  some  specific  microbe  or  virus,  but  hitherto  none  has 
been  isolated. 

In  consequence  of  this  condition  of  the  thyroid  a  marked 
alteration  takes  place  in  the  bodily  and  (usually)  mental  state 
of  the  person  affected.  In  congenital  or  infantile  cases  the  whole 
nutrition  of  the  body  is  disturbed.  The  child,  whilst  usually 
remaining  fat  and  puffy,  makes  very  little  growth,  and  the 
majority  of  these  persons  remain'Swarfs.  The  skin  is  sallow  or 
actually  yellow,  dry,  thickened,  and  wrinkled,  and  has  the 
appearance  of  being  too  large  for-  the  body.  The  head  is  large 
and  the  fontanelles  are  late  in  closing.  The  nose  is  broad  and 
flat,  the  lips  thick  and  swollen,  and  the  tongue  so  large  that  it 
often  hangs  out  of  the  open  mouth.  The  belly  is  protuberant, 
and  the  lower  limbs  short  and  bowed.  The  whole  body  is  un- 
wieldy, its  balance  unsteady,  and  its  gait  ungainly.  Puberty  is 
often  delayed,  and  many  pronounced  cretins  are  sterile.  In  fact, 
these  children  as  a  whole  present  bodily  signs  identical  with  those 
of  the  sporadic  variety.  In  those  cases  in  which  the  disease  is 
acquired  in  later  life,  as  a  consequence  of  residence  in  a  goitrous 
locality,  changes  analogous  to  those  occurring  in  myxoedema  are 
produced. 

It  has  been  stated  that  this  condition  of  athyroidea  may  exist 
without  any  mental  change,  and  although  this  may  sometimes 
be  true  where  the  disease  is  acquired  in  later  life,  and  also  in  very 
exceptional  instances  in  the  congenital  form,  there  is  usually 
produced  some  degree  of  mental  deficiency.  This  ranges  from 
a  mild  amount  of  feeble-mindedness  to  a  state  of  gross  idiocy, 
and  is  usually  accompanied  by  deafness.     The  report  of  the 


Secondary  Amentia  and  its  Clinical  Varieties  253 

Royal  Commission  of  Sardinia*  divides  cretins  into  the  following 
three  classes  : 

In  Class  I.  the  subjects  have  only  vegetative  faculties,  are 
entirely  destitute  of  reproductive  and  intellectual  powers,  and 
cannot  speak.     They  are  styled  simply  ''  cretins." 

In  Class  II.  they  have  vegetative  and  reproductive  faculties 
and  some  rudiments  of  language.  Their  intellectual  efforts  go 
no  farther  than  their  bodily  wants,  corresponding  only  to  the 
impression  of  the  senses.     They  are  called  "  semi-cretins." 

In  Class  III.  there  is  added  to  the  faculty  of  the  preceding  one 
a  greater  amount  of  intellectual  power  without  reaching  the 
normal  human  capacity.  They  have  some  aptitude  at  learning 
a  trade  or  doing  different  kinds  of  work.  They  are  called 
"cretineux,"  or  "cretinous." 

Sporadic  Cretinism  (Cretinoid,  Myxoedematous,  or  Pachydermic 
Amentia). — ^This  condition  was  first  described  by  the  late  Dr. 
Hilton  Fagge  in  1871,  and  although  since  then  a  considerable 
number  of  cases  have  been  reported,  it  is  nevertheless  a  rare 
disease.  Cretinoid  aments  do  not  compose  more  than  a  fraction 
per  cent,  of  all  aments. 

Although  sporadic  have  many  features  in  common  with 
endemic  cretins,  and  although  in  each  there  is  a  condition  of 
athyroidea,  there  are  several  important  points  of  difference 
between  the  two.  In  the  first  place,  whilst  a  goitre  is  generally 
present  in  the  endemic  form,  in  the  sporadic  cases  the  thyroid 
gland  is  usually  entirely  absent.  Secondly,  although  the  sporadic 
Gases  may  occur  in  regions  in  which  goitre  is  prevalent,  they  often 
crop  up  quite  apart  from  such  a  condition,  and  in  famiHes  and 
localities  in  which  goitre  is  unknown. 

Etiology. — ^This  raises  the  questions  of  the  cause  of  sporadic 
cretinism  and  its  relation  to  the  endemic  form.  In  a  few  of  the 
cases  coming  under  my  own  observation  I  found  a  marked  history 
of  morbid  neuropathic  heredity,  just  the  same  as  in  ordinary 
primary  aments,  and  this  led  me  to  make  further  inquiries  as  so 
the  prevalence  of  heredity  in  this  condition.  Several  consulting 
physicians,  having  a  considerable  experience  of  cretins,  and  who 

*  For  these  extracts,  as  well  as  much  information  on  the  subject  of 
endemic  cretinism,  I  am  indebted  to  the  excellent  account  in  Dr.  Ireland's 
work.  "^ 


c^ 


254  Mental  Deficiency 

were  good  enough  to  reply  to  my  inquiries,  informed  me  that  no 
special  neuropathic  heredity  had  been  noticed  ;  but  they  added 
that  the  majority  of  the  patients  had  been  seen  in  hospital 
practice,  and  no  special  attention  had  been  given  to  the  farnily 
history.  Dr.  John  Thomson  of  Edinburgh,  however,  had  fully 
investigated  the  family  history  in  seventeen  of  his  patients,  with 
the  following  result  :  In  nine  there  was  no  history  of  nervous  or 
mental  disease  or  of  alcoholism  ;  of  the  remaining  eight,  in  one  a 
brother  and  sister  were  dwarfs,  in  four  there  was  a  family  history 
of  mental  alienation,  and  in  another  of  epilepsy,  whilst  the  fathers 
of  the  remaining  two  patients  were  alcoholic. 

I  am  greatly  indebted  to  Dr.  Thomson  for  his  kindness  in 
supplying  me  with  these  details,  which  seem  to  show  that, 
although  on  the  whole  neuropathic  heredity  is  not  a  marked 
feature  of  this  condition,  such  nevertheless  occurs  in  a  propor- 
tion of  cases — that  it  is,  in  fact,  more  prevalent  in  cretins  than 
in  ordinary  persons.  Whether  in  such  cases  the  absence  of  the 
thyroid  gland  should  be  looked  upon  as  a  peculiar  stigma  of 
degeneracy  complicating  primary  amentia,  or  whether  it  is  that 
in  these  cases  the  athyroidea  is  due  to  the  same  unknown  cause 
as  in  the  non-hereditary  cases,  I  am  unable  to  say.  The  cause 
of  sporadic  cretinism  is  shrouded  in  so  much  mystery  as  to  be 
at  present  a  complete  enigma,  and  it  may  be  a  mere  chance  that 
the  neuropath  as  well  as  the  non-neuropath  should  be  affected. 
However  this  may  be,  it  is  possible  that  the  presence  of  morbid 
heredity  may  be  not  without  influence  in  affecting  the  response 
to  thyroid  treatment,  which,  although  in  many  cases  seemingly 
dependent  upon  the  age  at  which  it  is  begun,  is  not  entirely 
determined  thereby. 

Pathology. — ^Whatever  may  be  the  cause  of  the  thyroid 
anomaly,  there  is  not  the  slightest  doubt  that  the  secretion  of 
this  gland  exercises  a  profound  influence  upon  the  nutrition  of 
the  brain,  and  in  most,  if  not  all,  cases  of  cretinism  it  is  clearly 
to  the  absence  of  this  secretion  that  the  mental  peculiarity  is  due. 
It  is  of  interest  in  this  connexion  to  recall  the  state  of  mental 
hebetude,  in  some  cases  amounting  to  dementia,  which  results  in 
the  analogous  condition  of  myxoedema  seen  in  adults. 

The  defect  of  this  secretion  does  not  lead  to  any  characteristic 
lesion  of  the  brain.     The  neurones  are  simply  unable  to  develop 


Plate  XXI. 


be 

< 


To  face  page  254] 


or 


1 


k 


Secondary  Amentia  and  its  Clinical  Varieties    255 

and  to  perform  their  function  because  an  essential  constituent  of 
their  nutriment  is  lacking.  In  several  cases  which  have  been 
examined  after  death,  the  cortical  cells  have  been  found  in  a  con- 
dition of  incomplete  development,  like  that  already  described 
as  occurring  in  primary  amentia.  Sometimes,  in  addition,  the 
whole  brain  is  found  to  be  small  and  simply  convoluted. 

Clinical  Symptoms. — The  symptoms  of  sporadic  cretinism 
usually  make  their  appearanceThfrihg' The  first  year,  although 
they  are  rarely  noticeable  until  the  sixth  or  seventh  month. 
Exceptionally  they  may  not  occur  until  the  second  or  third,  or 
even  sixth  or  seventh  year,  but  such  cases  are  rare.  The  parents' 
attention  is  generally  first  attracted  by  the  fact  that  the  child 
neither  grows  so  rapidly  nor  appears  as  bright  mentally  as  a 
normal  child  of  corresponding  age  ;  also,  in  the  cases  with  early 
onset,  that  he  makes  no  attempt  to  sit  up,  to  stand,  or  to  talk. 
It  is  commonly  said  that  the  primary  dentition  is  considerably 
delayed,  but  Dr.  Thomson  doubts  this,  and  he  has  been  good 
enough  to  supply  me  with  details  of  ten  patients  regarding  this 
point,  from  which  it  appears  that,  in  the  absence  of  rickets,  the 
time  of  dentition  does  not  differ  markedly  from  that  of  ordinary 
children.  The  anterior  fontanelle  is  late  in  closing,  and  has  been 
observed  open  in  adults.  Attempts  at  walking  may  not  be  per- 
formed until  the  fifth  year  or  later.  Speech  may  be  delayed  until 
the  seventh  or  eighth  year,  and  may  never  appear.  Usually 
within  a  few  years  after  birth  the  child  has  assumed  the  charac- 
teristic cretinous  appearance. 

The  characteristic  features  of  the  fully  developed  condition  are 

as  follows  :  The  body  is  greatly  dwarfed,  and  many  children  of 

fifteen   or  sixteen   years   of   age    do    not    measure   more   than 

3  feet  in  height.     (The  accompanying  illustrations  (Plate  XXL, 

Figs.  51  and  52)  show  a  cretin,  aged  thirty-nine,  whose  height  is 

only  a  little  over  3  feet).     The  head  is  usually  large ;  the  legs 

are  extremely  short   and  bowed ;    the  hands  and  feet  stumpy 

and  ill-formed.     The  ossification  of  the  bones  is  delayed  con- 

^siderably    beyond    the    normal    period.       The    appearance    of 

i  the    face  alone    is   often    typical,   the   nose   being   broad   and 

.flattened,  the  eyes  widely  separated,  the  lips  thick,  the  mouth 

partly  open,  and  the  tongue  thick,  coarse  and  protruding.     In 

;  addition,  the  eyelids  are  often  heavy  and  swoUen,  and  the  hair 


256  Mental  Deficiency 

coarse  and  scanty.  A  very  important  feature  is  the  skin,  which 
is  sallow,  exceedingly  dry,  rough,  and  so  redundant  as  to  appear 
much  too  large  for  the  stunted  body.  Doubtless  this  is  the 
result  of  the  under-development  chiefly  affecting  the  tissues  of 
mesoblastic  origin.  The  neck  is  usually  short  and  thick  and  the 
belly  protuberant.     Umbilical  hernia  is  common. 

Puberty  is  usually  late  in  appearing,  and  the  external  genitals 
often  retain  an  infantile  appearance  until  past  mature  age. 
Many  of  these  patients  are  sterile.  In  the  majority  of  cases  the 
thyroid  gland  is  completely  absent,  and  in  a  considerable  number 
of  cases  there  are  small  soft  swellings  above  the  clavicles  or  in 
the  axillae.  These  are  apparently  fatty,  and  they  disappear 
rapidly  under  thyroid  treatment.  The  pulse  and  respiration  are 
slow,  and  the  temperature  two  or  three  degrees  below  the  normal. 
As  a  result  of  his  examination  of  the  blood,  Vaquez  found  that 
there  was  a  marked  diminution  in  the  number  of  the  red  cor- 
puscles, as  well  as  their  contained  haemoglobin,  with  an  excessive 
number  of  nucleated  corpuscles. 

These  children  are  often  voracious  eaters,  but,  although  well 
nourished  and  even  fat,  most  of  them  suffer  from  a  general  mus- 
cular weakness.  This,  together  with  their  mental  torpidity, 
causes  the  bodily  balance  to  be  unsteady,  the  gait  slow  and 
waddling,  and  all  movements  to  be  performed  with  a  laboured 
clumsiness.  These  bodily  peculiarities,  associated  as  they  are 
with  their  general  slothfulness,  apathy,  and  want  of  expression, 
produce  a  clinical  picture  which  can  rarely  be  mistaken. 

Mentally  these  persons  are  characterized  by  a  general  im- 
pairment of  all  the  faculties.  There  is  often  considerable  defect 
in  the  power  of  hearing,  but  beyond  an  obtuseness  of  percep- 
tion there  is  not  any  other  marked  abnormality  of  the  special 
senses.  Some  of  them  are  pronounced  imbeciles,  or  even  idiots, 
but  in  others  the  degree  of  mental  deficiency  is  one  of  mild  im- 
becility. Most  of  these  milder  cases  can  be  taught  to  read  and 
write  simple  words,  to  count,  to  do  little  sums  in  addition  and 
subtraction,  and  to  perform  small  tasks.  Others,  whilst  capable 
of  assisting  in  the  domestic  work  of  the  institution,  make  abso- 
lutely no  headway  in  book  learning.  Most  of  them  can  be  taught 
to  be  methodical  and  clean  in  their  habits.  As  a  class  they  are 
placid\  harmless,  good-tempered,  and  affectionate  ;  and  although 


Secondary  Amentia  and  its  Clinical  Varieties     257 

they  show  little  trace  of  emotion,  they  are  nevertheless  capable 
of  being  pleased  and  amused  in  a  dull,  heavy  sort  of  way.  They 
are  amongst  the  least  troublesome  of  all  aments. 

I  know  of  no  statistics  enabling  the  mortality  of  these  persons 
to  be  compared  with  that  of  ordinary  aments,  but  my  irnpression 
is  that  they  are  decidedly  less  frail,  and  not  so  prone  to  early 
death.  Phthisis  does  not  seem  to  be  nearly  so  common.  The 
oldest  cretin  I  know  is  an  imbecile  man  aged  sixty-three  years. 
He  is  looked  after  by  his  sister,  who  keeps  a  small  village  shop, 
and  he  is  apparently  in  good  bodily  health.  He  has  never  been 
under  thyroid  treatment. 

Diagnosis. — In  a  well-marked  case  of  sporadic  cretinism  the 
mental  and  bodily  conditions  are  sufficiently  characteristic  to 
make  the  diagnosis  easy.  But  all  cases  are  not  equally  well 
marked,  and  there  are  some  other  diseases  which,  owing  to  certain' 
points  of  resemblance,  may  be  thought  to  be  cretinism.  The 
converse  mistake,  except,  perhaps,  in  the  case  of  rickets,  is  less 
likely  to  be  made.  The  chief  of  these  are  rickets,  hydrocephalus, 
achondroplasia,  hypertrophic  and  Mongolian  amentia. 

1.  Rickets. — It  is  not  uncommon  for  early  cases  of  cretinism 
to  be  called  rickets,  but  the  characteristic  beading  of  the  ribs  and 
symmetrical  enlargement  of  the  epiphyses  in  this  latter  condition, 
with  the  absence  of  the  typical  cretinous  facies,  should  suffice  to 
distinguish  between  the  two. 

2.  Hydrocephalus. — The  only  points  in  common  are  the  large 
head,  the  muscular  weakness,  and  the  mental  apathy.  But  the 
enlarged  head  of  the  hydrocephalic  is  totally  different  to  that  of 
the  cretin,  and  the  mental  and  bodily  differences  between  these 
two  conditions  are  much  more  pronounced  than  are  the  resem- 
blances. 

-  3.  Achondroplasia,  although  very  rare,  is  often  called  cretinism. 
It  is  distinguished  by  the  facts  that,  although  the  child  is 
dwarfed  owing  to  imperfect  development  of  the  long  bones,  and 
although  the  skin  is  often  dry  and  somewhat  redundant,  there  is 
a  complete  absence  of  the  swollen  eyelids,  the  broad,  squat  nose, 
the  enlarged  tongue  and  mouth  of  the  cretin.  Moreover,  the 
mental  development  is  unaffected,  and  children  suffering  from 
achondroplasia  are  intelligent  and  vivacious. 

4.  Hypertrophic  A  ments  resemble  cretins  in  the  large  head  and 

17 


258  Mental  Deficiency 

somewhat  stunted  body,  and  the  resemblance  may  be  intensified 
by  the  tottering  gait,  general  muscular  weakness,  and  mental 
inertia.  But  the  facies  of  the  hypertrophic  are  different :  the 
skin  lacks  the  dryness  and  redundancy  of  the  cretin,  and  has  not 
the  same  bogginess  ;  there  is,  as  a  rule,  no  delay  in  the  develop- 
ment of  puberty,  and  there  is  not  the  same  subnormal  tempera- 
ture. Moreover,  the  hypertrophic  ament  complains  of  head  pain, 
and  is  often  subject  to  outbreaks  of  temper  and  excitement  which 
are  totally  foreign  to  the  lethargic,  inert  cretin. 

5.  Mongolian  Aments  are  frequently  thought  to  be  cretins, 
and  were  for  a  long  time  called  *'  cretinoids."  The  differential 
diagnosis  has  been  given  on  p.  189. 

Treatment  and  its  Result. — That  this  condition  is  the  result  of 
an  absent  or  defective  secretion  of  the  thyroid  gland  is  fully 
shown  by  the  remarkable  results  which  follow  thyroid  administra- 
tion. Under  its  influence  the  characteristic  facies  disappear, 
the  skin  becomes  moist  and  supple,  the  body  rapidly  increases  in 
growth,  and  in  many  cases  a  marked  improvement  takes  place 
in  the  mental  condition.  But  to  obtain  this  favourable  result 
the  treatment  must  be  continuous,  and  it  must  be  begun  at  a 
sufficiently  early  age. 

The  effect  of  thyroid  treatment  is  decidedly  more  uncertain 
and  less  pronounced  upon  the  mental  than  the  bodily  develop- 
ment. To  a  great  extent  this  appears  to  be  dependent  upon  the 
age  at  which  it  is  commenced,  but  there  may  be  other  factors 
which  influence  the  result.  Dr.  G.  A.  Sutherland  mentioned  to 
me  the  case  of  one  of  his  patients  in  whom  the  disease  was  diag- 
nosed at  the  age  of  three  months,  and  who  after  continuous  treat- 
ment for  six  years  showed  no  mental  impairment.  Dr.  Robert 
Hutchison  tells  me  of  a  case  of  his  which  has  been  treated  from 
the  third  month,  and  now,  at  the  age  of  fifteen  years,  is  appar- 
ently of  normal  mental  capacity.  Dr.  George  Murray,  of  New- 
castle, has  also  experienced  such  a  satisfactory  result.  Dr.  John 
Thomson  has  supplied  me  with  particulars  of  a  boy  where  treat- 
ment was  begun  at  the  age  of  seven  and  a  half  months,  and  who 
now,  at  the  age  of  eleven  and  a  half  years,  is  so  far  improved  that 
he  reads  and  spells  as  well  as  the  average  of  his  age,  his  only 
noticeable  weakness  being  in  arithmetic.  Another  patient  of 
Dr.  Thomson's  was  started  upon  thyroid  at  the  age  of  seven  and 


Secondary  Amentia  and  its  Clinical  Varieties     259 

a  half  weeks,  and  now,  at  six  and  a  half  years,  is  of  normal 
appearance,  somewhat  above  the  average  height,  and,  although 
not  very  energetic,  appears  to  be  of  normal  intelligence.  Another 
case  is  that  of  a  girl  who  has  been  under  treatment  since  the  age 
of  four  years  eleven  months.  She  reached  the  sixth  standard  at 
school,  but  never  did  much  at  arithmetic.  She  is  now  engaged 
as  a  compositor  in  a  printing-office,  but,  owing  to  her  slowness  in 
lifting  the  type,  only  earns  half  the  wage  of  other  girls  of  similar 
age  doing  the  same  work. 

It  must  be  admitted,  however,  that  such  cases  are  somewhat  ex- 
ceptional and  not  the  rule,  and  it  is  the  general  experience  of  those 
who  have  knowledge  of  these  persons  that  the  mental  is  rarely 
commensurate  with  the  bodily  development.  I  have  in  my  care 
at  the  present  time  a  patient  who  is  an  excellent  illustration  of 
this  fact.  He  was  sent  to  me  at  the  age  of  eight  years  by  Dr. 
Soltau  Fenwick,  with  a  letter  to  the  effect  that  it  was  a  case  of 
cretinism  which  had  been  under  treatment  since  infancy,  and  had 
improved  wonderfully  in  all  but  the  mental  symptoms.  I  could 
detect  absolutely  no  bodily  sign  of  cretinism,  and,  instead  of  the 
torpid  mental  state  characteristic  of  that  condition,  he  was  alert 
and  active.  But  the  boy  was  a  pronounced  imbecile,  and  he  has 
made  but  little  improvement  under  special  training.  In  this  case 
there  is  marked  neuropathic  heredity,  and  the  mother  has  been 
insane  in  an  asylum.  Dr.  Robert  Hutchison  tells  me  of  a  similar 
case  which  he  has  treated  continuously  since  the  seventh 
month,  and  yet  the  child  is  a  hopeless  imbecile,  although  not  in 
the  least  like  a  cretin  in  appearance.  Perhaps  these  instances 
represent  the  opposite  extreme,  for  I  think  it  is  somewhat  unusual 
for  mental  improvement  to  be  so  slight  where  treatment  is 
begun  thus  early. 

In  many  patients  improvement  takes  place  at  an  even  later 
age.  Dr.  Caldecott,  of  Earlswood  Asylum,  has  at  the  present 
time  in  his  care  a  cretin  who  was  admitted  at  the  age  of  fourteen 
years.  She  could  not  walk,  talk,  nor  swallow  solid  food,  and  her 
mental  status  was  that  of  a  low-grade  idiot.  She  had  never  been 
treated  with  thyroid.  After  three  years'  treatment  she  has  grown 
12  inches,  can  walk  and  run  about,  talks  fairly  distinctly,  and  is 
taking  her  place  in  school. 

On  the  whole,  I  think  it  may  be  laid  down  that,  whilst  in  some 

17 — 2 


26o  Mental  Deficiency 

cases  cure  may  take  place  if  treatment  be  initiated  not  later  than 
the  third  month,  should  the  first  year  be  allowed  to  pass  without 
thyroid  administration,  the  cretin,  although  improving  to  some 
extent,  will  never  make  up  his  mental  arrears. 

The  most  convenient  method  of  treatment  is  by  means  of 
tabloids  of  the  dried  extract.  Usually  for  a  child  of  from  three  to 
six  months  a  dose  of  \  grain  once  or  twice  daily  will  be  found 
appropriate.  This  must  be  gradually  increased  at  the  rate  of 
I  grain  per  diem  for  each  year  of  the  child's  age,  with  a  maximum 
of  15  grains.  Treatment  must  be  continued  after  the  symptoms 
have  disappeared,  or  a  relapse  will  ensue  ;  but  usually  an  occa- 
sional large  dose  is  sufficient  to  maintain  the  effect. 

The  thyroid  must  be  given  cautiously  at  first,  and  the  dose  in- 
creased very  gradually.  In  some  cases  it  causes  diarrhoea,  rise 
of  temperature,  and  marked  acceleration  of  the  heart,  apparently 
as  a  result  of  the  increased  metabolism.  It  should  then  be  dis- 
continued for  a  time,  and  again  cautiously  resumed.  The  exces- 
sive growth  of  the  long  bones  may  cause  them  to  readily  bend, 
and  in  order  to  prevent  serious  curvatures  movement  must  be 
carefully  supervised. 

In  connexion  with  the  subject  of  cretinism  I  may  mention  the 
following  curious  case  of  temporary  cessation  of  mental  and 
bodily  development  occurring  in  a  girl  at  the  age  of  puberty.  I 
have  never  seen  a  similar  case  described,  and  the  only  explana- 
tion I  can  suggest  is  that  for  some  reason  or  other  the  secretion  of 
the  thyroid  gland  was  temporarily  suspended.  When  I  first  saw 
the  girl  she  was  seventeen  years  of  age,  but  in  height,  manner,  and 
general  development  she  had  the  appearance  of  a  child  of  twelve 
or  thirteen.  Her  mental  condition  was  backward  and  corre- 
sponded to  a  similar  age,  and  she  had  never  menstruated.  The 
mother  informed  me  that  the  girl  had  seemed  quite  all  right  in 
mind  and  body  until  about  four  years  previously,  but  since  then 
she  had  been  at  a  complete  standstill.  On  examination  the 
thyroid  gland  appeared  to  be  normal,  but  the  skin  was  sallow, 
coarse,  dry,  and  had  a  curious  boggy  feel,  the  hair  scanty,  the 
mons  veneris  uncovered,  the  lips  thick,  and  the  teeth  much 
decayed.  There  was  also  a  pronounced  flush  over  each  cheek. 
She  was  extremely  childish  for  her  age,  besides  being  unusually 
torpid  in  thought  and  movement.     In  view  of  these  symptoms, 


Secondary  Amentia  and  its  Clinical  Varieties    261 

I  decided  to  try  the  effect  of  th5n:oid  treatment.  The  mother 
noticed  improvement  after  the  first  week,  and  after  three  months 
menstruation  had  appeared  and  a  great  change  was  evident  in 
every  way.  She  was  under  treatment  for  about  nine  months, 
and  it  was  then  discontinued  entirely.  The  mental  and  bodily 
improvement  initiated  by  the  thyroid  steadily  continued,  and 
when  I  last  saw  her,  at  the  age  of  twenty-one  years,  she  had  a 
normal  appearance,  and  was  regularly  employed  as  a  clerk  in 
the  Post  Office. 


AMENTIA  DUE  TO  OTHER  NUTRITIONAL  DEFECTS. 

In  addition  to  the  secretion  of  the  thyroid  gland,  it  is  possible 
that  there  may  be  other  internal  secretions  or  chemical  com- 
pounds which  are  essential  to  the  growth  of  the  nerve  cells,  and 
the  absence  of  which  gives  rise  to  mental  deficiency.  For 
instance,  it  may  be  that  some  such  special  defect  is  re- 
sponsible for  the  curious  combination  of  bodily  anomalies 
present  in  Mongolism.  This,  however,  is  mere  conjecture.  At 
present  we  know  of  no  special  nutritive  agent  other  than  the 
thyroid  secretion,  and  the  cases  of  amentia  which  we  have  now 
briefly  to  consider  are  those  associated  with  a  general  defect  of 
the  bodily  nutrition. 

A  state  of  general  malnutrition  may  be  present  during  intra- 
or  extra-uterine  existence,  and  is  by  no  means  of  infrequent 
occurrence.  In  some  cases  the  cause  is  obscure  ;  in  others  the 
condition  is  obviously  the  result  of  insufficient  or  improper  feed- 
ing, dirt,  want  of  fresh  air  and  sunlight,  and  general  neglect. 
The  atmosphere  of  ignorance,  superstition,  and  indifference  which 
surrounds  the  early  infancy  of  a  large  number  of  the  children  of 
this  country,  particularly  in  large  towns,  is  wellnigh  incredible. 
In  other  cases  the  malnutrition  is  the  result  of  actual  disease, 
although  this  is  more  often  than  not  due  to  preventable  causes 
and  an  absolute  ignorance  or  defiance  of  the  laws  of  health. 

In  view  of  the  obvious  effects  which  such  adverse  environment 
exercises  upon  the  physical  condition  of  the  growing  child,  and 
being  aware,  from  our  knowledge  of  anatomy  and  physiology, 
of  the  immense  importance  of  a  copious  and  pure  blood-supply 
to  mental  activity,  it  is  not  unnatural  to  conclude  that  serious 


262  Mental   Deficiency- 

bodily  malnutrition  should  have  a  deleterious  effect  upon  the 
mental  development  of  the  infant.  To  a  certain  extent  such  a 
conclusion  is  correct.  Although  in  many  instances  the  ill-fed 
and  ill- washed  street  gamin  is  far  from  unintelligent,  experience 
does  on  the  whole  confirm  the  saying,  Mens  smta  in  corpore  sano, 
and  in  a  large  proportion  of  such  children  the  mental  develop- 
ment is  decidedly  inferior  to  that  of  a  healthy  child  of  corre- 
sponding age.  It  is,  however,  necessary  clearly  to  distinguish 
between  mental  development  which  is  backward  and  delayed  and 
that  which  is  arrested.  I  have  already  referred  to  this  subject 
in  treating  of  mentally  defective  children,  and  pointed  out  that, 
whilst  many  of  those  suffering  from  delayed  development  closely 
simulate  aments,  there  is  in  fact  no  real  arrest,  and  under  more 
favourable  conditions  the  arrears  are  soon  made  up.  It  is  prob- 
able that  in  some  cases  the  deprivation  of  nourishment  at  a  time 
when  the  cerebral  neurones  should  be  growing  rapidly  is  so 
severe  as  to  bring  about  permanent  effects.  I  have,  indeed, 
examined  a  few  cases  in  which  I  could  find  no  other  cause.  But 
in  my  opinion  this  is  exceedingly  uncommon.  I  have  never 
known  idiocy,  or  even  imbecility,  to  result ;  the  mental  deficiency 
is  always  mild,  and  the  proportion  of  aments  who  owe  their 
condition  to  bodily  malnutrition  is  really  infinitesimal.  In  some 
cases  the  malnutrition  may  play  the  part  of  an  exciting  factor, 
and  be  aU  that  is  needed  to  produce  an  actual  arrest  in  a  person 
whose  neuronic  potentiality  is  low  as  a  result  of  morbid  heredity. 
It  has  already  been  pointed  out  that  a  large  number  of  primary 
aments  suffer  from  defective  bodily  nutrition  as  a  consequence 
of  the  improper  working  of  their  nervous  system.  It  is  very 
necessary  to  bear  this  fact  in  mind  in  considering  this  question, 
and  to  avoid  mistaking  cause  for  effect. 

One  of  the  commonest  disturbances  of  nutrition  occurring  in 
j^^  infancy  is  that  due  to  rickets,  and  a  "  rachitic  idiocy  "  has  been 
described.  I  have  never  seen  such  a  case.  Rickets  may,  of 
course,  complicate  primary  or  secondary  amentia,  and  there  can 
be  no  doubt  that  the  mental  development  of  the  rachitic  child 
is  often  delayed  and  abnormal ;  but,  so  far  as  my  experience  goes, 
rickets  alone  has  never  produced  amentia.  On  the  contrary,  I 
know  several  adults  of  marked  intellectual  ability  who  show 
clear  evidence  of  having  suffered  from  severe  rickets  in  childhood. 


Secondary  Amentia  and  its  Clinical  Varieties    263 

With  regard  to  cases  of  amentia  due  to  congenital  syphilis,  as 
already  stated,  it  seems  to  me  more  probable  that  these  are  the 
result  of  a  direct  toxic  action  than  of  a  disturbance  of  nutrition. 


AMENTIA  DUE  TO  ISOLATION  OR  SENSE  DEPRIVATION. 

The  growdng  brain  cells  not  only  require  to  be  supplied  with 
their  own  particular  food,  but  they  must  also  be  stimulated  by 
vibrations  transmitted  through  the  special  sense  pathways.  The 
effect  of  these  is  probably  similar  to  that  produced  by  rays  of 
light  upon  plant  development,  and  in  their  absence  cellular 
gro\\i:h  is  as  imperfect  as  if  the  brain  had  been  starved.  This  is 
well  shown  by  the  marked  agenesis  of  the  occipital  cortex  which 
occurs  as  a  consequence  of  congenital  non-development  of  the 
organs  of  vision — a  fact  which  has  been  ably  utilized  by 
J.  S.  Bolton  to  accurately  map  out  the  visual  area.  But  not 
only  are  sensations  thus  necessary  for  growth :  they  are  also 
the  materials  out  of  which  thoughts  and  ideas  are  built,  and 
the  sum  total  of  them  constitutes  mind.  Should,  therefore, 
a  single  sensory  avenue  be  closed,  as  in  bHndness  or  deafness, 
the  mind  must  for  ever  remain  the  poorer  by  the  impressions 
which  would  have  entered  through  this  channel,  and  if  two  or 
more  senses  are  defective  the  mind  may  be  so  impoverished 
as  to  bring  about  a  condition  of  true  amentia. 

As  we  have  already  seen,  such  sensory  defects  are  occasionally  ^ 
present  in  primary  amentia,  and  they  are  then  a  compHcation 
which  usually  imposes  an  insuperable  obstacle  to  successful  train- 
ing. In  secondary  amentia,  however,  which  we  are  now  con- 
sidering, there  is  no  intrinsic  incapacity  of  the  cortical  neurones, 
and  if  other  sensory  channels  can  be  so  utilized  as  to  in  some 
degree  compensate  for  those  diseased,  the  mental  capacity  may 
be  but  little  impaired.  Suitable  training  may  therefore  prevent 
secondary  amentia  from  these  causes.  That  this  is  so  is  fully 
shown  by  the  excellent  results  achieved  in  training  estabhsh- 
ments  for  the  blind  and  deaf,  as  well  as  by  some  classical  examples 
in  which  disease  of  several  sensory  channels  had  existed. 

The  common  cause  of  the  sensory  deprivation  in  these 
cases  is  inflammation  resulting  from  one  or  other  of  the  in- 


264  Mental  Deficiency 

fectious  fevers  ;  the  lesion  is  usually  at  the  periphery,  and  the 
organs  most  frequently  affected  are  those  of  sight  and  hearing. 
Amentia  can  only  result  when  such  occurs  during  early  child- 
hood (whilst  cerebral  development  is  immature),  and  where 
special  educational  training  has  been  withheld  or  has  failed.  In 
the  absence  of  a  neuropathic  inheritance  I  believe  failure  to  be 
exceedingly  rare,  and  the  cases  of  this  form  of  amentia  which  are 
met  with  are  nearly  always  in  persons  whose  early  education  has 
been  neglected.  They  are,  in  fact,  as  much  sufferers  from  a 
deprivation  of  special  education  as  of  special  sense.  I  have  met 
several  such  cases  in  remote  country  districts.  The  child, 
deprived  of  sight  or  hearing  in  early  life,  is  thereby  excluded 
from  the  village  school.  The  local  authority  provides  no  special 
form  of  education,  and  does  not  further  concern  itself  with  him. 
There  may  be  institutions  for  the  blind  and  deaf  but  ten  miles 
away,  but  it  is  no  particular  person's  business  to  secure  him 
admission,  and  he  gradually  grows  up  without  any  training. 
He  soon  passes  the  age  at  which  such  would  be  of  avail,  and 
becomes  an  incurable  ament.  Although  such  a  state  of  affairs 
still  exists,  it  is  less  common  than  in  years  gone  by.  The  neces- 
sity for,  and  great  benefit  to  be  derived  from,  training  is  now 
much  more  generally  recognized,  and  in  consequence  cases  of 
amentia  due  to  sense  deprivation  are  not  nearly  so  prevalent  as 
formerly.  At  the  present  time  they  comprise  only  a  fraction  of 
all  cases  of  amentia,  although  the  total  number  in  existence  is 
still  considerable. 

These  patients  are  usually  well  grown  and  free  from  any  stig- 
mata of  degeneracy.  In  the  majority  of  instances  the  mental 
defect  is  mild,  but  it  is  not  uncommon  for  it  to  be  accompanied 
by  hallucinations  and  delusions,  and  sometimes  the  behaviour  is 
so  erratic  and  untrustworthy  as  to  necessitate  committal  to  an 
asylum  for  the  insane. 

Illustrative  Cases. 

The  two  following  are  good  examples  of  this  form  of  amentia 
as  commonly  met  with  : 

Mild  Amentia  consequent  upon  Early  Deafness. — W.  S.,  male, 
fifteen  years  of  age.  No  morbid  heredity.  Was  either  born  deaf 
or  became  so  shortly  after  birth,  and  has  never  spoken.     He  was 


Secondary  Amentia  and  its   Clinical  Varieties  265 

refused  admission  to  the  village  school,  and  has  received  no 
education.  He  is  weir  grown  for  his  age,  and  has  a  pleasing  ex- 
pression. He  can  understand  many  signs,  and  can  express 
many  of  his  wants  in  the  same  way.  Beyond  helping  his  mother 
in  the  house  at  times,  he  is  quite  unemployed.  He  is  by  no 
means  lacking  in  the  faculties  of  imitation  and  imagination,  and 
is  fond  of  drawing  on  a  slate  or  scraps  of  paper.  It  is  quite  evi- 
dent, however,  that  his  ideas  are  extremely  crude  and  childish. 
In  addition  to  his  intellectual  defect,  he  has  little  power  of  con- 
trol, and  is  becoming  more  and  more  subject  to  outbreaks  of 
passion  and  waywardness.  On  several  occasions  he  has  wandered 
away  from  home.  His  mother  states  that  he  is  affectionate, 
but  "  cannot  bear  to  be  crossed."  I  am  of  opinion  that  in  this 
case  suitable  training  in  a  school  for  the  deaf  would  have  pre- 
vented the  mild  amentia  now  present,  and  would  have  resulted 
in  the  patient  becoming  a  useful  member  of  society.  Even  at  this 
age  I  strongly  urged  the  desirability  of  such  training,  as  with- 
out it  there  is  no  doubt  that  he  will  gradually  become  more 
intractable,  and  will  finally  drift  into  an  insane  asylum. 

The  Earlswood  case  also  is  probably  one  of  amentia  due  to 
deafness,  but  as  this  patient  has  developed  a  most  extraordinary 
degree  of  mechanical  skill,  I  have  thought  it  better  to  describe 
him  under  the  chapter  on  Idiots  Savants. 

Mild  Amentia  consequent  upon  Congenital  Blindness. — E.  W.  C, 
male.  Born  blind.  No  education.  Admitted  into  imbecile  in- 
stitution at  the  age  of  fifteen,  but  found  to  be  intractable  and 
violent,  and  transferred  to  lunatic  asylum. 

He  is  now  twenty-nine  years  of  age,  and  is  a  tall,  well-developed 
and  well -nourished  man  of  pleasing  expression.  Cranial  circum- 
ference, 22|  inches.  No  stigmata  of  degeneracy.  He  is  quite 
blind,  the  eyes  being  represented  by  rudimentary  bulbs  of  white 
sclerotic  tissue  without  any  indication  of  cornea  or  iris.  His 
memory  is  good  ;  he  has  a  tolerably  good  knowledge  of  places  and 
events,  can  understand  all  that  is  said  to  him,  and  can  give  a 
fair  account  of  himself.  He  possesses  imagination,  but  his  ideas 
are  simple  and  childish,  and  his  power  of  reasoning  is  decidedly 
defective.  He  cannot  read,  write,  sum,  or  do  any  kind  of  work, 
and  he  spends  the  day  rocking  himself  to  and  fro  in  a  chair 
and   muttering   to   himself.     After   answering   a    question,    he 


266  Mental  Deficiency 

rambles  on  to  himself  in  an  incoherent  way  about  analogies 
and  philosophy.  When  asked  what  a  philosopher  is,  he  says  : 
**  A  man  who  tries  to  make  everybody  else  better."  He  then 
immediately  goes  on  to  talk  about  Ally  Sloper,  which,  he  says, 
has  been  read  to  him.  He  has  aural  hallucinations  and  delusions, 
and  is  very  emotional  and  untrustworthy.  In  spite  of  his  beatific 
appearance,  he  is  liable  to  frequent  outbreaks  of  sudden  violence, 
and  has  repeatedly  attacked  the  other  patients.  He.  is  also  a 
confirmed  masturbator.     (See  Plate  XXII.,  Fig.  53.) 

The  following  well-known  cases  may  be  briefly  referred  to  in 
this  place,  as  showing  the  really  remarkable  results  which  may 
attend  the  systematic  education  of  patients  suffering  from  severe 
sense  deprivation. 

Laura  Dewey  Bridgman.* — An  attack  of  scarlet  fever  at  the 
age  of  two  years  caused  suppuration  of  both  eyes  and  both  ears  ; 
taste  and  smell  were  also  impaired.  She  was  quite  deaf,  and  sight 
was  entirely  abolished  in  the  left  eye ;  but  she  retained  a  slight 
perception  of  light  in  the  right  eye  up  to  the  eighth  year,  after 
which  she  became  completely  blind.  She  was  admitted  to  the 
Perkins  Institution  for  the  Blind  at  Massachusetts  at  the  age 
of  seven  years  ten  months,  and  received  systematic  education 
under  Dr.  Howe  until  she  was  twenty.  Owing  to  the  unremitting 
care  and  patience  of  Dr.  Howe  in  training  her  cutaneous  sensation 
(the  only  sense  unimpaired),  she  became  able  to  read  and  write 
in  the  deaf  and  dumb  language,  to  express  many  of  her  feelings, 
to  sew,  knit,  and  perform  certain  household  duties,  and,  in  short, 
to  live  to  a  great  extent  the  life  of  an  ordinary  person.  She 
remained  in  the  Perkins  Institution  until  her  death,  at  the  age 
of  sixty  years.  The  general  conclusion  arrived  at  regarding  her 
by  Mr.  Sangford  was  that  "  she  was  eccentric,  not  defective ; 
she  lacked  certain  data  of  thought,  but  not  in  a  very  marked  way 
the  power  to  use  what  data  she  had." 

♦  See  the  "  Life  of  Laura  Bridgman,"  by  M.  S.  Lamson,  Boston,  1878  ; 
also  an  account  by  Dr.  Howe  in  the  Forty-Third  Annual  Report  of  the 
Perkins  Institution  and  Massachusetts  Asylum  for  the  Blind,  A  very 
good  abstract  of  this  is  given  by  Dr.  Ireland  in  his  "  Mental  Affections  of 
Children." 

The  brain  was  very  carefully  examined  by  Dr.  H.  H.  Donaldson,  and 
described  by  him  in  the  American  Journal  of  Psychology,  September,  1890, 
and  December,  1891. 


Plate  XXII. 


<  S 


<'^ 


To  face  page  266. 


^-'^l^'-'of   THE      ' 
OF 


Secondary  Amentia  and  its  Clinical  Varieties    267 

The  post-mortem  examination  showed  that  the  auditory 
nerves,  the  optic  nerves  and  tracts,  and  the  olfactory  bulbs,  were 
very  small.  The  grey  matter  of  the  cortex  generally  was  thinner 
than  usual,  especially  in  the  occipital,  cuneus,  and  temporal 
lobes.  In  these  situations  there  was  also  a  deficiency  in  the 
number  of  nerve  cells.  There  was  a  considerable  non-develop- 
ment of  the  inferior  frontal  and  temporo-sphenoidal  convolu- 
tions covering  the  island  of  Reil,  particularly  marked  on  the  left 
side.     The  cranial  circumference  was  20"8  inches. 

In  two  other  pupils  of  the  Perkins  Institution — namely,  Oliver 
Caswell  and  Helen.  Keller — the  results  were  almost  equally 
remarkable.  The  former  of  these  was  blind  and  deaf  from  infancy, 
and  the  latter  lost  sight  and  hearing  at  the  age  of  nineteen 
months. 

Meystre,  of  Lausanne  (Switzerland),  was  born  deaf  and  dumb, 
and  he  lost  his  sight  by  an  accident  at  the  age  of  five  years. 
By  unremitting  attention  he  was  taught  to  articulate,  and  at 
the  age  of  eighteen  he  was  described  as  "  a  lively,  intelligent, 
and  good-humoured  fellow,  an  excellent  carpenter,  a  first-rate 
turner,  and  runs  about  the  building  with  a  certainty  and  confi- 
dence which  none  of  the  merely  blind  pupils  acquire.  He  has  a 
great  many  ideas,  and  an  instinctive  dread  of  death." 

Agnes  Halonen*  was  born  in  Finland  in  1886.  At  the  age  of 
eighteen  months  she  became  blind  from  scarlet  fever,  and  a  year 
afterwards  became  deaf.  She  very  soon  ceased  to  speak,  and 
expressed  her  wants  by  means  of  a  few  simple  signs,  such  as 
putting  her  hand  to  her  mouth  when  she  wanted  food.  She 
could  recognize  members  of  her  family  by  touch.  At  the  age  of 
eight  she  was  sent  to  the  Blind  School  at  Helsingfors.  Here  she 
was  taught  to  sew  and  knit,  as  well  as  the  finger  alphabet.  At 
the  age  of  seventeen  she  could  read  books  in  Braille  and  Moon's 
characters,  and  she  could  also  write.  She  had  some  knowledge 
of  geography,  which  had  been  taught  her  by  means  of  raised 
maps.  She  knew  many  of  the  capitals,  mountains,  and  rivers 
in  Europe  and  Asia,  and  she  had  a  knowledge  of  the  habits  of 
plants  and  animals.  She  was  able  to  sew,  spin,  crochet,  plait, 
and  make  brushes,  and  generally  was  very  intelligent. 

*  "  The  Blind  Deaf-Mute,  Agnes  Halonen,"  by  Aug.  Helin,  Stockholm. 
Abstract  in  Journal  of  Mental  Science,  April,  1904,  p.  ^^6. 


268  Mental   Deficiency 

Kaspar  Hauser. — No  account  of  this  subject  would  be  complete 
without  a  brief  reference  to  this  celebrated  and  mysterious  case. 
It  differs  from  the  foregoing  in  that  there  was  no  disease  of  the 
sensory  pathways,  but  the  environment  of  the  child  for  many 
years  was  such  that  they  could  not  be  exercised.  It  may  fittingly 
be  described  as  a  case  of  mental  arrest  due  to  isolation. 

On  May  26,  1828,  a  youth,  apparently  about  sixteen  or  seven- 
teen years  of  age,  was  found  near  one  of  the  gates  of  Nuremberg. 
He  was  unable  to  give  any  account  of  himself,  and  inquiries 
failed  to  discover  how  or  whence  he  came  or  who  he  was.  He 
was  4  feet  9  inches  in  height,  very  pale,  with  short,  delicate  beard 
on  his  chin  and  upper  lip.  His  feet  were  tender  and  blistered, 
and  showed  no  signs  of  having  been  confined  in  shoes.  He 
scarcely  knew  how  to  use  his  fingers  or  hands,  and  his  attempts 
at  walking  resembled  the  first  efforts  of  a  child.  He  could  not 
understand  what  was  said  to  him,  and  replied  to  all  questions  by 
a  single  phrase  :  "  I  will  be  a  trooper,  as  my  father  was."  His 
countenance  was  expressive  of  gross  stupidity.  He  appeared  to 
be  hungry  and  thirsty,  but  refused  everything  offered  to  him 
except  bread  and  water.  He  held  in  his  hand  a  letter  stating 
that  the  bearer  had  been  left  with  the  writer,  who  was  a  poor 
labourer  with  ten  children,  in  October,  1812,  and  who,  not 
knowing  his  parents,  had  brought  him  up  in  his  house,  without 
allowing  him  to  stir  out  of  it.  This  was  regarded  as  being 
intended  to  deceive.  Upon  a  pen  being  place^lin  his  hand,  the 
youth  wrote  the  words  ''Kaspar  Hauser." 

After  an  official  inquiry — which,  however,  revealed  nothing — 
he  was  adopted  by  the  town  of  Nuremberg,  and  Professor  Daumer 
undertook  his  education.  He  was  found  to  be  extremely  child- 
like, and  to  have  no  knowledge  of  the  most  simple  facts  of  every- 
day life.  He  had  a  remarkable  faculty  of  smell  and  for  seeing 
things  in  the  dark,  however,  and  under  the  instruction  of  Daumer 
his  mind  expanded  in  a  wonderful  manner.  In  fact,  probably 
as  a  consequence  of  its  sudden  awakening  into  activity,  he 
became  ill,  and  his  education  had  to  be  discontinued  for  a  time. 

He  was  taught  the  use  of  language,  and  after  a  time  was  able 
to  record  his  recollections.  He  said  that  he  had  always  lived  in  a 
small,  dark  cell,  continually  seated  on  the  ground.  He  had  had 
no  covering,  except  a  shirt  and  trousers,  and  had  never  seen  the 


Secondary  Amentia  and  its  Clinical  Varieties    269 

sky.  When  he  awoke  from  sleep  he  was  accustomed  to  find  near 
him  some  bread  and  a  pitcher  of  water,  but  he  never  saw  the  face 
of  the  person  who  brought  them,  and  he  had  no  knowledge  that 
there  were  any  other  living  creatures  besides  himself  and  the 
man  who  brought  him  food.  This  man  eventually  taught  him 
to  write  his  own  name,  and  finally  brought  him  to  the  Nuremberg 
gate. 

For  a  time  mental  development  took  place  with  great  rapidity, 
but  the  prolonged  isolation  had  wrought  an  effect  upon  the  brain 
cells  from  which  they  could  not  completely  recover,  and  after  a 
time  their  potentiality  became  exhausted  and  no  further  progress 
was  made.  He  was  taken  under  the  protection  of  Lord  Stanhope, 
and  he  was  subsequently  employed  in  the  Court  of  Appeal,  but 
he  showed  little  real  capacity  for  work.  On  October  17,  1829, 
he  was  found  bleeding  from  a  slight  wound  which  he  said  had  been 
inflicted  by  a  stranger.  On  December  14,  1833,  at  Anspach,  he 
met  a  stranger  by  appointment,  on  the  promise  that  the  mystery 
of  his  birth  would  be  revealed.  During  the  interview  he  was 
mortally  stabbed,  and  he  died  three  days  afterwards. 

A  post-mortem  examination  showed  a  somewhat  thickened 
skull  and  rather  small  brain,  which  did  not  completely  overlap 
the  cerebellum.  The  convolutions  of  the  brain  were  also  simpler 
than  normal. 

The  mystery  of  Kaspar  Hauser's  birth  and  death  attracted 
widespread  interest,  and  has  never  been  solved.  It  was  con- 
tended by  Earl  Stanhope  and  the  Duchess  of  Cleveland  that  he 
was  an  impostor,  but  this  view  was  strongly  combated  by  both 
Professor  Daumer  and  the  eminent  Bavarian  jurist,  Von  Feuer- 
bach.  The  latter  considered  that  Hauser  was  heir  to  a  princely 
German  house,  put  out  of  the  way  to  favour  another  succession. 
A  careful  examination  of  the  facts  regarding  his  condition  when 
first  found,  his  subsequent  limited  progress,  his  untimely  and 
mysterious  death,  and  the  state  of  his  brain,  seem  to  show  that 
his  account  was  a  truthful  one,  and  that  he  exemplifies  in  a  unique 
manner  the  effects  of  a  prolonged  isolation  upon  the  cells  of  the 
brain. 


CHAPTER  XIV 

IDIOTS  SAVANTS 

We  have  seen  that  amentia  is  often  characterized  by  an  irregular 
as  well  as  a  defective  mental  development,  and  in  a  small  number 
of  patients  this  is  so  marked  as  to  result  in  special  aptitudes 
which  are  quite  phenomenal,  not  merely  in  comparison  with 
aments,  but  often  with  the  acquirements  of  ordinary  persons. 
These  persons  are  conveniently  described  as  "  idiots  savants." 
The  condition  is  exceptional  and  relatively  uncommon  ;  on  the 
other  hand,  it  is  not  so  rare  but  that  a  considerable  number  of 
cases  have  been  recorded. 

Presumably  the  special  aptitude  is  related  to  an  increased  de- 
velopment of  certain  cerebral  neurones,  but  as  to  how  and  why 
this  is  brought  about  we  can  only  conjecture.  In  many  of  the 
cases  I  have  seen  there  has  been  a  clearly  marked  predilection 
(which,  however,  has  rarely  been  marked  in  the  ancestors),  and 
I  can  only  assume  that  this  is  the  result  either  of  some  primary 
developmental  anomaly  or  of  some  fortuitous  circumstance  of 
early  life  which  has  aroused  the  child's  interest  in  a  particular 
direction,  and  thence  led  to  the  concentration  of  all  his  mental 
activities  upon  the  one  object.  On  the  whole,  I  think  that  most 
of  these  cases  are  explicable  on  this  latter  view.  The  talent, 
whatever  it  is,  and  however  originating,  certainly  owes  much  of 
its  development  to  constant  exercise. 

It  is  to  be  noticed  that  although  these  persons  are  spoken  of 
as  "  idiots,"  they  are  rarely  of  the  lowest  grade  of  mental  defect. 
Most  of  them  would  more  properly  be  classed  as  imbeciles  or 
merely  feeble-minded.  It  is  remarkable,  however,  that  they 
almost  invariably  belong  to  the  male  sex,  female  idiots  savants 
being  almost  unknown. 

270 


Idiots  Savants  271 

Peterson  is  of  opinion  that  the  talents  of  these  persons  lie 
chiefly  in  the  direction  of  imitation,  and  that  they  have  no 
capacity  for  origination.  He  also  thinks  that  they  are  frequently 
lost  before  adult  life.  These  statements  are  undoubtedly  true 
of  many  cases,  byt  they  are  by  no  means  invariable.  I  doubt 
whether  the  latter  one  is  even  the  rule,  and  several  illustrations 
to  the  contrary  will  be  cited  in  the  following  pages. 

The  nature  of  these  phenomenal  acquirements  varies  con- 
siderably. In  some  persons  the  talent  consists  of  an  extra- 
ordinary development  of  one  of  the  special  senses.  Thus,  Jules 
Voisin  describes  the  case  of  an  imbecile  with  a  wonderful  delicacy 
of  smell.  She  never  ate  or  drank  anything  without  smelling  it, 
and  if  given  coffee  (for  which  she  had  a  great  fondness)  in  a  glass 
which  had  contained  wine,  she  would  at  once  detect  it  and  refuse 
to  drink.  Imbeciles  have  been  described  who  were  able  by  the 
sense  of  smell  to  pick  out  their  own  and  their  companions'  clothes, 
and  Seguin  noticed  many  idiots  even,  in  whom  this  faculty  was 
developed  to  an  extraordinary  degree. 

In  other  cases  there  is  an  increased  development  of  the  visual 
sense.  Several  of  the  drawing  and  mechanical  geniuses  have  a 
wonderful  capacity  for  detecting  slight  differences  of  form  and 
size,  whilst  the  following  case,  mentioned  to  me  by  Dr.  R.  Langdon 
Down,  is  an  excellent  example  of  this  class.  It  is  that  of  a  boy, 
a  patient  at  Normansfield,  whose  hobby  was  the  collection  of  small 
bright  articles  of  any  description,  and  this  interest  had  so  cul- 
tivated his  quickness  and  sharpness  of  sight  that  nothing  in  the 
shape  of  a  pin,  a  minute  fragment  of  broken  glass,  or  any  shining 
particle,  which  was  invisible  to  the  ordinary  person,  ever  escaped 
him.  Other  patients  have  a  phenomenal  auditory  capacity — as, 
for  example,  the  wild  boy  of  Aveyron  described  by  Itard,  as  well 
as  some  who  will  presently  be  mentioned  on  account  of  their  speech 
and  memory.  Finally,  there  are  some  cases  in  which  the  hyper- 
development  concerns  the  t^tile  sense.  Dr.  R.  Langdon  Down 
tells  me  that  there  used  to  be  aTtJDy  at  Normansfield  whose  sense 
of  touch  was  so  dehcate  and  fingers  so  deft  that  he  could  take  a 
page  of  the  Graphic  and  gradually  split  it  into  two  perfect  sheets, 
as  one  would  peel  a  postage  stamp  off  an  envelope. 

In  another  group  of  cases  it  is  chiefly  in  the  motor  functions 
that   these  extraordinary  talents  he.     Sometimes  there  is   an 


272  Mental  Deficiency 

almost  incredible  capacity  for  the  performance  of  mechanical 
work  requiring  the  greatest  cunning  and  dexterity,  and  as  an 
example  of  this  the  Earlswood  case,  which  will  presently  be 
described,  is  probably  unique.  In  other  persons  the  gift  takes 
the  form  of  drawing,  and  many  of  the  walls  of  Earlswood  Asylum 
are  at  the  present  time  adorned  by  beautifully  executed  crayon 
drawings  (copies  of  well-known  pictures)  which  were  done  by  the 
mentally  deficient  brother  of  the  patient  just  referred  to.  Occa- 
sionally the  talent  for  drawing  passes  beyond  mere  picture-copy- 
ing, as  in  the  celebrated  case  of  Gottfried  Mind.  This  person, 
who  died  at  Berne  in  1814,  was  a  cretin  imbecile  with  such  a 
marvellous  faculty  for  drawing  pictures  of  cats  that  he  was  known 
as  "  Der  Katzen- Raphael." 

Under  the  heading  of  motor  we  may  also  describe  those  cases 
possessing,  if  not  the  gift  of  tongues,  at  all  events  an  extra- 
ordinary capacity  for  reproducing  spoken  words.  Dr.  Martin  W. 
Barr*  describes  an  epileptic  idiot,  aged  twenty-two  years,  who, 
in  spite  of  the  most  careful  teaching,  could  learn  neither  to  read 
nor  to  write,  although  he  was  able  to  perform  small  domestic 
duties.  Spontaneously  he  hardly  spoke  at  all,  and  then  only 
short  disconnected  words  or  the  simplest  sentences  ;  but  he  had 
an  extraordinary  capacity  for  repeating  fluently  and  with  proper 
intonation  everything  said  to  him,  whether  in  his  mother-tongue 
or  in  such  languages  as  Greek,  Japanese,  Danish,  Spanish,  etc. 
Probably  those  cases  in  which  an  imbecile  will  reel  off,  verbatim, 
cantos  of  poetry  also  belong  to  this  category. 

In  a  considerable  proportion  of  these  idiots  savants  the  gift  is 
one  of  memory  in  some  form  or  other,  and  of  this  many  interesting 
and  remarkable  examples  have  been  described.  At  the  present 
time  there  are  two  such  in  Earlswood  Asylum.  One  of  them  is  a 
man,  sixty-five  years  of  age,  suffering  from  high-grade  amentia, 
whose  penchant  is  biographical  history.  It  is  only  necessary  to 
mention  to  him  the  name  of  any  prominent  personage  in  early  or 
ancient  history,  and  out  there  flows  in  a  steady,  unhesitating 
stream  a  full  and  detailed  account  of  his  birth,  life,  and  death. 
His  knowledge  has  been  acquired  by  poring  over  biographical 
details  in  such  books  as  were  available,  and  is,  of  course,  simply 

*  M.  W.  Barr,  "Some  Notes  on  Echolalia,"  Journal  of  Nervous  and 
Mental  Diseases,  January,  1898. 


Idiots  Savants  273 

a  matter  of  memory.  It  is  not,  however,  merely  repetitive,  for 
he  stands  cross-questioning  in  a  manner  which  shows  that  he 
has  some  knowledge,  although  not  full  understanding,  of  the 
occurrences  he  is  talking  about.  Dr.  Caldecott  tells  me  that 
until  the  last  few  years  there  has  been  no  decline  in  this  man's 
capacity ;  latterly,  however,  he  has  begun  to  show  signs  of  mental 
and  bodily  old  age.  The  other  case  is  a  somewhat  younger  man, 
aged  fifty-six  years,  whose  memory  also  relates  to  dates  and 
occurrences,  but  only  such  as  have  come  under  his  own  notice. 
He  is  a  most  valuable  referee  on  matters  connected  with  the 
previous  life  of  the  institution,  and  can  repeat  the  year,  month, 
and  day  of  coming  and  going,  of  all  the  medical  officers  during 
his  period  of  residence. 

Dr.  R.  Langdon  Down  showed  me  a  similar  case  at  Normans- 
field,  the  patient  being  a  high-grade  imbecile  thirty-eight  years 
of  age.  In  this  case  the  phenomenal  memory  chiefly  relates  to 
number,  but  the  patient  also  has  a  pronounced  sense  of  locality. 
His  speciality  is  the  calendar,  and  if  given  any  date  during  the 
last  five  years,  he  states  the  correct  day  without  any  hesitation. 
But  he  seems  almost  equally  at  home  with  the  hymn-book,  and 
will  promptly  give  the  number  of  any  hymn  of  which  he  is  given 
the  first  line,  or  vice  versa.  His  home  is  near  Maida  Vale,  and 
on  being  asked  what  streets  he  would  have  to  pass  through  in 
going  home  from  Waterloo  terminus  he  named  each  one  without 
the  slightest  hesitation.  This  patient  can  also  give  the  product 
of  any  two  numbers  under  twenty  with  the  rapidity  of  a  reflex 
movement. 

Dr.  Forbes  Winslow*  mentions  the  case  of  a  man  who  could 
remember  "  the  day  when  every  person  had  been  buried  in  the 
parish  for  thirty-five  years,  and  could  repeat  with  unvarying 
accuracy  the  name  and  age  of  the  deceased,  and  the  mourners 
at  the  funeral.  But  he  was  a  complete  fool.  Out  of  the  line 
of  burials  he  had  not  one  idea,  could  not  give  an  intelligible 
reply  to  a  single  question,  nor  be  trusted  even  to  feed  himself." 

Other  cases  show  the  existence  of  this  phenomenal  memory  in 
its  simplest  automatic  form.  Thus,  there  are  many  idiots  who 
cannot  speak  a  single  word,  and  yet  can  hum  a  tune,  which  they 
have  only  heard  once,  with  perfect  accuracy.    Other  aments  will 

*  Quoted  by  Ireland. 

18 


274  Mental  Deficiency 

reel  off  poetry  almost  ad  infinitum,  yet  without  any  understand- 
ing of  the  sense  of  what  they  are  saying,  or  even  the  meaning  of 
the  words.  Dr.  Langdon  Down  has  described  the  case  of  a  boy 
who,  having  read  a  book,  would  correctly  recite  whole  pages 
word  for  word.  Dr.  Maudsley  mentions  the  case  of  an  imbecile 
who  could  similarly  repeat  verbatim  a  newspaper  he  had  just 
read,  as  well  as  another  more  remarkable  patient  who  could 
repeat  backwards  what  he  had  just  read. 

Most  aments  are  fond  of  music,  and  some  particularly  so,  but 
in  a  few  instances  this  propensity  has  an  extraordinary  develop- 
ment. One  of  the  most  striking  examples  of  this  is  furnished 
by  Dr.  Trelat,  and  this  case  is  also  interesting  in  being  a  female. 
Dr.  Trelat*  says  that  "  they  had  in  the  Salpetri^re  an  imbecile 
born  blind,  affected  with  rickets,  and  crippled,  who  had  great 
musical  talents.  Her  voice  was  very  correct,  and  whenever  she 
had  sung  or  heard  some  piece  she  knew  perfectly  well  the. words 
and  the  music.  As  long  as  she  lived  they  came  to  her  to  correct 
the  mistakes  in  singing  of  her  companions  ;  they  asked  her  to 
repeat  a  passage  which  had  gone  wrong,  which  she  always  did 
admirably.  One  day,  G^raldy  Liszt  and  Meyerbeer  came  to  the 
humble  singing-class  of  our  asylum  to  bring  her  their  encouraging 
consolations."  Dr.  Seguin  also  records  several  cases  in  which  a 
pronounced  musical  capacity  was  present. 

Lastly,  in  marked  contradiction  to  the  general  failing  of  aments 
in  this  respect,  a  few  of  these  persons  have  an  extraordinary 
capacity  for  arithmetic  and  calculations.  One  case  described 
-by  Dr.  J.  Langdon  Down  is  that  of  an  inmate  of  Earlswood 
Asylum,  an  imbecile  boy  of  twelve  years,  who  could  multiply 
three  figures  by  three  other  figures  with  lightning  rapidity. 
Dr.  Howe  has  also  recorded  the  case  of  a  low-grade  ament  who, 
if  told  the  age  of  anyone,  would  in  a  very  short  time  calculate 
the  number  of  minutes  he  had  lived.  Dr.  Wizelf  also  records 
the  case  of  an  imbecile  (apparently  suffering  from  secondary 
amentia)  who  had  a  most  remarkable  faculty  for  arithmetic, 
particularly  multiplication. 

We  may  conclude  this  chapter  on  idiots  savants  with  an  accouni 
of  the  following  extremely  interesting  case  : 

*  Trelat,  "La  Folie  Lucide,"  etc.,  Paris,  1861.     Quoted  by  Ireland, 
•j-  Archiv  fiir  Psychiat.,  Band  xxxviii.,  Heft  i. 


Idiots  Savants 


275 


The  Genius  of  Earlswood  Asylum. 

Since  the  year  1850  there  has  been  resident  in  Earlswood 
Asylum  a  patient  who  has  justly  earned  this  title,  and  whose 
skill  in  drawing,  invention,  and  mechanical  dexterity  is  certainly 
unequalled  by  an  inmate  of  any  similar  institution  in  existence. 
At  the  present  time,  although  seventy-three  years  of  age,  he  still 
continues  to  be  actively  engaged  in  his  workshop.  I  am  greatly 
indebted  to  Dr.  Caldecott  for  his  kindness  in  giving  me  permis- 
sion to  examine  this  patient  and  his  wonderful  productions  ;  also 
for  freely  placing  at  my  disposal  a  mass  of  particulars  and  photo- 
graphs regarding  him  which  he  has  taken  great  trouble  to  collect. 

/.  H.  Pullen  was  born  in  the  year  1835.  The  family  history 
is  somewhat  scanty,  for  the  reason  that  the  only  informant  now 
available  is  the  patient's  sister ;  but,  as  far  as  can  be  ascertained, 
the  parents  and  grandparents  were  steady,  sober,  hard-working 
people,  and  there  is  no  history  of  insanity,  epilepsy,  or  any  of 
the  usual  antecedents  of  primary  amentia.  The  parents,  how- 
ever, were  first  cousins.  Of  thirteen  children  born  in  the  family, 
six  died  in  infancy,  and  of  the  remaining  seven  only  three  are 
now  living.  It  is  extremely  interesting  to  note  that  another 
brother  was  deaf  and  dumb,  and  had  an  even  greater  aptitude 
for  drawing  than  the  patient ;  he  died  in  Earlswood  Asylum  of 
cancer  at  the  age  of  thirty-five  years. 

There  are  no  particulars  as  to  the  age  at  which  the  patient 
began  to  walk,  but  he  did  not  talk  until  seven  years,  and  for  a 
long  time  only  uttered  the  word  *'  muvver."  He  never  went  to 
school,  as  no  school  would  take  him.  He  showed  an  early  taste 
for  drawing,  and  used  to  spend  the  greater  part  of  his  time  at 
this  occupation  or  in  carving  ships  out  of  bits  of  firewood.  Such 
instruction  as  he  had  he  received  from  his  parents  and  brothers 
and  sisters  at  home,  and  from  these  he  learned  to  write  and  spell 
the  names  of  simple  objects,  but  this  was  practically  the  sum 
total  of  his  scholastic  acquirements. 

Pullen  was  admitted  to  Earlswood  Asylum  at  the  age  of  fifteen 
years.  On  admission  he  WcLS  found  to  be  active  and  well 
grown,  his  height  being  5  feet  7 J  inches,  and  his  weight  9  stones 
II  pounds.     The  cranial  circumference  was  2r|  inches.     He  was 

1 8—2 


276  Mental  Deficiency 

described  as  having  a  good  memory  and  power  of  imitation,  and 
as  being  fond  of  drawing  and  examining  how  things  were  made. 
His  senses  of  taste,  smell,  and  touch  were  good  ;  he  was  able  to 
wash,  dress,  and  take  care  of  his  person,  but  his  speech  was  very 
imperfect  and  he  was  very  deaf. 

He  was  put  to  work  in  the  carpenter's  shop,  and  soon  became 
an  expert  craftsman.  It  was  clear,  moreover,  that  he  possessed 
a  capacity  for  initiation,  imagination,  resource,  and  attention  far 
above  the  other  inmates,  and  in  consequence  he  was  allowed 
considerable  liberty  of  action  and  freedom  to  follow  his  own  bent. 
The  result,  after  sixty  years,  is  to  be  seen  in  the  fifty  to  sixty 
crayon  drawings,  the  carvings  in  ivory  and  wood,  and  the  wonder- 
ful models  of  ships  and  the  like,  which  to-day  adorn  the  walls  and 
fill  the  two  large  workrooms  placed  at  his  disposal  in  Earlswood 
Asylum.  Some  idea  of  his  skill  in  drawing  and  mechanical  in- 
vention will  be  gathered  from  the  accompanying  photographs  of 
his  work  (Plates  XXHI.,  XXIV.,  XXV.),  but,  as  Dr.  Caldecott 
very  truly  says,  it  is  difficult  by  this  means  to  really  appreciate 
their  beauty,  to  do  which  the  originals  must  be  seen. 

Pullen  has  designed  and  drawn  a  pictorial  history  of  his  life, 
which  shows  his  chief  occupations  between  the  years  1841  and 
1873.     A  reproduction  of  this  is  given  in  Fig.  55. 

One  of  the  most  wonderful  of  his  works,  and  the  one  of  which 
he  is  the  most  proud,  is  the  model  of  a  steamship  which  he  has 
named  the  Great  Eastern.  This,  I  think,  he  rightly  regards  as 
his  magnum  opus,  and  it  attracted  universal  admiration  at  the 
Fisheries  Exhibition,  where  it  was  shown  in  the  year  1883.  It 
took  him  three  years  and  three  months  to  complete,  and  every 
detail,  including  brass  anchors,  screw,  pulley-blocks,  and  copper 
paddles,  were  actually  made  by  the  patient  from  careful  drawings, 
which  he  prepared  beforehand.  The  planks  of  this  leviathan  are 
fixed  to  the  ribs  by  wooden  pins  to  the  number  of  nearly  a  million 
and  a  quarter.  All  of  these  were  made  by  Pullen  in  a  special 
instrument,  which  in  turn  he  also  planned  and  made.  He  also 
devised  and  executed  a  strong  carriage  on  four  wheels  for  the 
conveyance  of  the  ship.  The  model  is  10  feet  long,  i8f  inches 
wide,  and  13I  inches  in  depth.  It  contains  5,585  copper  rivets, 
and  there  are  thirteen  lifeboats  hoisted  on  complete  davits,  each 
of  which  is  a  perfectly  finished  model.     It  is  fitted  with  paddles, 


Plate  XXIII. 


•r  t^ 

&  00 

O   - 

ii 


ii 


-aS 


O    0} 


To  face  page  276.] 


Idiots   Savants  277 

screw,  and  engines,  and  it  contains  state  cabins,  which  are 
decorated  and  furnished  with  chairs,  tables,  beds,  and  bunks.  In 
fact,  the  whole  thing  is  complete  to  the  most  minute  detail,  and 
will  bear  the  closest  inspection.  (See  Fig.  59.)  He  has  invented 
and  attached  an  arrangement  of  pulleys  by  which  the  whole  upper 
deck  may  be  raised  so  as  to  show  the  parts  below.  I  believe 
that  when  first  put  into  water  the  huge  model  capsized,  but  that 
has  since  been  remedied.  It  is  perhaps  hardly  to  be  expected 
that  a  person  with  no  knowledge  of  practical  boat-building  should 
succeed  in  making  a  vessel  that  would  be  really  navigable,  but 
as  a  highly  finished  model  it  is  unmatched  in  its  completeness. 

Another  of  PuUen's  productions  is  an  immense  but  most  beauti- 
fully finished  kite  in  the  form  of  a  ship  under  fuU  sail.  Another 
is  a  fully  rigged  man-of-war  of  the  old  wooden  type.  This  is 
copper-riveted,  and  contains  forty-two  brass  cannon,  all  of  which 
were  made  by  the  patient.  The  rigging  contains  200  pulley-blocks, 
all  capable  of  working.  (See  Fig.  57.)  Another  production,  which 
testifies  to  his  imaginative  as  well  as  mechanical  faculty,  consists 
of  a  fantastic  barge  most  beautifully  carved  out  of  ivory,  ebony, 
and  various  fancy  woods.  Upon  the  prow  are  seated  four  angels 
carved  out  of  ivory,  whilst  the  stern  is  occupied  by  a  figure  of 
His  Satanic  Majesty.  There  are  twelve  oars,  beautifully  jointed, 
and  worked  mechanically  from  one  centre  rod. 

One  of  his  most  recent  pieces  of  work  is  the  representation  of 
a  monstrous  human  form  about  13  feet  high.  This  black-bearded, 
terrible-looking  figure  is  armed  with  a  gigantic  sword,  and  can 
be  made  to  perform  a  variety  of  movements,  such  as  opening  and 
shutting  the  mouth  and  eyes,  protruding  the  tongue,  rotating 
the  head,  raising  the  arms,  etc.,  by  means  of  a  most  elaborate 
internal  mechanism.  It  is  calculated  to  strike  terror  into  the 
heart  of  any  juvenile  beholder.  Of  this,  with  the  White  Knight, 
he  may  truly  say,  "  It's  my  own  invention." 

Other  productions  include  bookcases,  chairs,  tables,  work- 
benches, picture-frames,  and  the  like  ;  in  fact,  the  list  of  his  work 
during  the  fifty-eight  years  he  has  been  in  the  asylum  would 
alone  fill  several  pages  of  this  book. 

In  disposition  Pullen  is  usually  quiet,  weU-behaved,  and  good- 
tempered,  and  he  seems  to  be  perfectly  happy  so  long  as  he  is 
allowed  to  work  out  his  own  ideas  when  and  how  he  pleases. 


278  Mental  Deficiency 

He  is  intolerant  of  supervision,  inclined  to  be  suspicious  of 
strangers,  and  easily  affronted  by  injudicious  busy-bodies.  At 
times  he  gets  a  little  out  of  hand,  and  if  denied  requests  which 
are  quite  unreasonable  is  apt  to  become  sulky  or  passionate. 
On  one  occasion  he  threatened  to  blow  up  the  place  because  a 
request  had  been  refused,  and  it  is  quite  likely  that  he  would 
have  attempted  to  do  so  had  he  not  been  mollified.  On  another 
occasion  he  did  actually  partially  wreck  his  workshop  in  a  fit  of 
passion.  Many  years  ago  there  was  a  steward  of  the  asylum  to 
whom  Pullen  took  a  violent  dislike,  and  he  spent  many  days 
planning  his  destruction.  This  culminated  in  the  erection  over 
the  door  of  a  most  diabolical  instrument,  which  was  intended  to 
guillotine  the  unfortunate  officer,  and  there  is  not  the  slightest 
doubt  that  it  would  have  done  so  had  it  not  gone  off  a  fraction 
of  a  second  too  late. 

He  once  became  enamoured  of  a  female  whom  he  had  chanced 
to  meet  outside  the  asylum.  Nothing  would  satisfy  him  but 
that  he  should  have  his  discharge  and  be  allowed  to  marry  her. 
He  moped  about,  utterly  refused  to  do  any  work  or  to  listen  to 
argument  or  persuasion,  and  it  became  clear  that  the  position 
was  critical.  A  happy  inspiration  occurred  to  a  member  of  the 
committee,  and  a  gorgeous  naval  uniform,  resplendent  in  blue 
and  gold,  was  procured.  Pullen  was  invited  into  the  board-room 
and  informed  that  his  case  had  been  carefully  considered,  and 
that  it  had  been  decided  to  accede  to  his  request.  At  the  same 
time  it  was  pointed  out  to  him  that  the  committee  would  be 
exceedingly  sorry  to  lose  his  valuable  services,  and  that,  if  he 
would  reconsider  the  matter,  they  would,  as  an  alternative, 
grant  him  a  commission  as  Admiral  in  the  Navy.  The  uniform 
was  then  shown  to  him  as  an  earnest  of  their  intention.  This 
was  too  much  for  Pullen  ;  he  took  the  uniform,  and  has  never 
since  alluded  to  the  subject  of  marriage.  This  uniform  he  usually 
dons  on  ceremonious  occasions.     (See  Fig.  54.) 

A  note  in  the  case-book  describes  him  as  "  the  quintessence  of 
self-conceit,"  and  a  consuming  vanity  and  almost  overwhelming 
sense  of  his  own  cleverness  and  importance  are  very  marked 
characteristics.  Whilst  showing  me  his  handiwork  he  frequently 
stopped  to  pat  his  head  and  say,  **  Very  clever  ";  and  when  I 
produced  a  tape  measure  and  asked  permission  to  ascertain  the 


Plate  XXIV. 
PRODUCTIONS   OF  THE   "GENIUS"   OF  EARLSWOOD   ASYLUM. 


Fig.  56. — A  crayon  copy  of  the  celebrated  picture  "Bolton  Ahhcy 


Fig.  57.-rA  fully-rigged  man-of-war  of  the  old  wooden  type,  and  carriage,  with  the  maker. 
To  face  page  278.] 


\> 


^ttAI^^ 


OF   TH6 


UNIVERSITY 

^  OF 


Idiots  Savants  279 

extent  of  his  cranial  capacity  he  was  dehghted,  and  evidently- 
regarded  me  as  a  very  sensible  fellow.  At  the  same  time,  in 
spite  of  his  childish  egotism,  he  is  by  no  means  deficient  in  some 
power  of  looking  after  himself,  and  on  several  occasions  he  has 
been  found  selling  privately  and  for  his  own  advantage  little 
articles  he  has  made.  Many  of  his  works  are  carried  out  under 
the  real  or  pretended  idea  that  he  has  a  commission  for  them  at 
a  contract  price,  and  this  childish  fancy,  as  well  as  his  extremely 
limited  vocabulary,  is  illustrated  by  his  private  memorandum- 
book,  the  photograph  of  a  page  of  which  is  shown  in  Fig.  58. 

What  conclusion  are  we  to  come  to  regarding  the  causation 
and  pathology,  even  the  mental  status,  of  this  remarkable  man  ? 
His  powers  of  observation,  comparison,  attention,  memory,  will, 
and  pertinacity,  are  extraordinary,  as  is  fully  shown  by  the  fore- 
going account ;  and  yet  he  is  obviously  too  childish,  and  at  the 
same  time  too  emotional,  unstable,  and  lacking  in  mental  balance, 
to  make  any  headway,  or  even  to  hold  his  own,  in  the  outside 
world.  Without  some  one  to  stage-manage  him,  his  remarkable 
gifts  would  never  suffice  to  supply  him  with  the  necessities  of 
life,  or  even  if  they  did,  he  would  speedily  succumb  to  his  utter 
want  of  ordinary  prudence  and  foresight  and  his  defect  of  com- 
mon sense.  In  spite  of  his  delicacy  of  manipulation  he  has  never 
learned  to  read  or  write  beyond  the  simplest  words  of  one  syllable. 
He  can  understand  a  little  of  what  is  said  to  him  by  lip-reading, 
and  more  by  signs,  but,  beyond  a  few  words,  nearly  all  that  he  says 
in  reply  is  absolutely  unintelligible. 

My  own  conclusion,  based  upon  several  interviews  and  upon 
the  particulars  supplied  me  by  Dr.  Caldecott,  is  that  the  case  is  not 
one  of  primary  amentia  at  all,  but  that  it  should  really  be  classed 
as  an  example  of  mild  secondary  mental  deficiency  due  to  sense 
deprivation  (deafness).  Whether  this  deafness  is  the  result  of  a 
congenital  deficiency  of  the  auditory  mechanism  or  is  due  to 
disease  I  am  unable  to  say,  as  the  particulars  of  his  early  life  are 
unfortunately  very  meagre  ;  but  I  am  inclined  to  think  that  it 
was  owing  to  this  deprivation  that  he  was  refused  admission  to 
school,  that  he  was  to  a  great  extent  cut  off  from  intercourse 
with  his  fellows,  and  that  he  grew  up  uninstructed  in,  and 
ignorant  of,  ordinary  scholastic  attainments  and  the  ways  of 
the  world.     Left  largely  to  himself,  his  amusement  consisted  in 


zSo  Mental  Deficiency 

copying  drawings  and  carving  bits  of  firewood,  as  I  have  seen 
in  other  cases  of  early  deafness.  His  isolated  condition  caused 
all  the  powers  of  his  mind  (which  do  not  seem  to  me  to  have  been 
intrinsically  defective)  to  be  devoted  to,  and  concentrated  upon, 
these  occupations,  with  the  result  that  he  developed  a  power  of 
copying  drawings,  of  carving  in  wood  (and  later  in  ivory),  and 
a  general  mechanical  dexterity  of  the  very  highest  order.  The 
curious  combination  of  extreme  ability  in  these  particulars,  with 
his  general  childish  simplicity,  his  egotism,  suspicion  of  strangers, 
sullen  or  passionate  outbreaks  if  thwarted,  and,  in  fact,  the 
whole  of  his  mental  characteristics,  are,  I  think,  explicable  in 
this  view.  The  condition  is  similar  in  kind,  although  differing 
in  degree,  to  that  frequently  seen  in  neglected  cases  of  congenital 
deafness,  and  it  is  not  greatly  dissimilar  to  that  of  some  non- 
idiotic  savants  who,  absorbed  in  their  one  particular  subject, 
have  gradually  lost  interest  in,  and  severed  their  connexion 
with,  the  outer  world. 


Plate  XXV. 
PRODUCTIONS   OF  THE   "GENIUS"   OF   EARLSWOOD  ASYLUM. 


3t 


4-3 


.-^' 


'^r^ 


M- 


^Jr->t:  rS 


'.^ 


in 


—  /^^^ 


S""!-  ^^'^' 


'An. 


Jw/^pi/^^  ^: 


/S6S 


fQ/^A' 


#?^^^c 


—  ^//t^ 


■^7m. 


Fig.  58.— Photograph  of  the  first  page  of  the  patient's  private  memorandum  book. 


Fig.  59. — The  Great  Eastern,  with  its  carriage,  as  exhibited  at  the 
Fisheries  Exhibition,  1S83.     {For  description  see  Text.) 


To  face  ^age  280.] 


^     OF   THE 

UNIVERSITY 

OF 


CHAPTER  XV 

THE  AMENT  AND  SOCIETY— PAUPER  AMENTS 

Hitherto  we  have  been  chiefly  concerned  with  aments  as  indi- 
viduals ;  in  the  next  three  chapters  it  is  proposed  to  deal  with 
them  as  members  of  the  community,  and  to  refer  to  such  of  their 
characteristics  as  concern  their  relationship  to  society.  Until  the 
last  few  years  no  reliable,  and  at  the  same  time  extensive,  statistics 
referring  to  the  ament  as  a  citizen  have  existed.  The  extremely 
valuable  ones  we  now  possess  are  due  in  great  measure  to  the 
investigations  instituted  by  the  Royal  Commission  of  1904.*  Of 
these  I  shall  make  full  use.  I  know  of  no  similar  inquiry  or 
statistics  concerning  any  other  country. 

Location  of  the  Mentally  Deficient. 

We  may  first  of  all  consider  the  location  of  these  persons. 
This  is  shown  by  Table  V.  on  p.  12,  which  relates  to  eleven 
selected  areas  of  England  and  Wales,  having  an  aggregate 
population  of  2,321,567.  The  areas  investigated  were  the  three 
large  towns  of  Manchester,  Birmingham,  and  Hull ;  the  two 
industrial  areas  of  Stoke-upon-Trent  and  part  of  the  mining 
county  of  Durham ;  two  mixed  industrial  and  agricultural  areas 
in  Carmarthenshire  and  Nottinghamshire  ;  and  four  rural  areas  in 
Somersetshire,  Wiltshire,  Lincolnshire,  and  Carnarvonshire.  The 
selection  is  thus  representative  of  the  entire  country.  This  table 
is  based  upon  the  returns  of  the  Royal  Commission,  to  which, 
however,  are  added  those  aments  confined  in  county  and  borough 
asylums,  and  certified  under  the  Lunacy  Act,  these  not  being 
included  in  the  Commission's  inquiry. 

It  is  seen  from  this  table  that  the  total  number  of  aments 

*  See  Report  of  the  Royal  Commission  on  the  Care  and  Control  of  the 
Feeble-Minded,  particularly  vol.  vi.,  dealing  with  the  medical  investigations. 

281 


282  Mental  Deficiency 

resident  in  institutions  or  in  receipt  of  outdoor  relief — that  is, 
wholly  or  partially  supported  by  the  public  (Classes  A  and  B) — is 
40*5  per  cent,  of  the  whole  number.  A  few  of  those  in  asylums  are 
probably  paying  patients,  but  their  number  is  so  small  as  to  be 
negligible.  But  this  proportion  is  relative  to  a  total  which 
includes  the  juvenile  feeble-minded  in  schools,  and  there  can  be 
no  doubt  that  a  large  number  of  these,  upon  attaining  the  age 
of  sixteen  years,  will  go  to  swell  the  ranks  of  the  pauper  class.  If 
these  mentally  defective  school-children  be  excluded,  it  is  found 
that  the  number  partially  or  entirely  supported  by  the  public  in 
each  respective  degree  of  amentia,  is  as  follows  :  Feeble-minded 
adults,  67  per  cent. ;  imbeciles,  52  per  cent. ;  idiots,  54  per  cent. 

The  proportion  of  aments  who,  to  all  intents  and  purposes, 
may  be  looked  upon  as  paupers  is  thus  seen  to  be  a  large  one,  but 
this  is  only  what  would  be  expected  in  view  of  their  mental 
disabilities,  often  combined  with  antisocial  propensities,  which 
we  have  already  described.  It  will  be  of  interest  to  consider 
the  degrees  of  amentia  separately. 

Feeble-minded. — With  regard  to  the  adult  feeble-minded,  it  is 
a  striking  fact  that  nearly  two-fifths  of  the  total  number  dis- 
covered were  found  within  Poor- Law  institutions.  From  careful 
inquiry  into  the  history  of  those  in  the  Somersetshire  area,  I  found 
that  they  fell  into  the  following  groups,  and  the  same  is  probably 
true  of  the  country  generally : 

(a)  Those  born  in  the  House,  nearly  always  illegitimate. 

(b)  Those  admitted  in  consequence  of  inability  to  earn  their 
Uving.  Most  of  these  are  below  middle  age  ;  they  include  vagrants 
and  street  loafers  brought  in  by  the  police,  and  a  small  section  of 
"  ins-and-outs  "  driven  in  by  stress  of  weather. 

(c)  Those  admitted  in  consequence  of  the  death  of  parents  or 
relations  who  have  hitherto  looked  after  them. 

(d)  Women  admitted  into  the  maternity  wards. 

The  economic  disadvantage  of  such  a  large  proportion  of 
these  persons  being  resident  in  workhouses  is  obvious  when  it  is 
stated  that  the  majority  are  not  in  the  declining  years  of  life,  but 
are  young  adults,  and  that  comparatively  few  of  them  are  re- 
muneratively employed. 

The  inquiries  show  that  more  than  half  are  below  forty-five 
years  of  age,  whilst  from  one-fourth  to  one-third  are  below  thirty. 


The  Ament  and  Society — Pauper  Aments     283 

It  was  the  general  experience  of  the  investigators  that  more  were 
admitted  between  the  ages  of  twenty  and  thirty  years  than 
during  any  other  decade.  This  tendency  for  the  feeble-minded 
to  drift  into  the  workhouse  quite  early  in  life  is  even  more  pro- 
nounced in  the  large  towns,  and  Dr.  Melland  found  that  in  Man- 
chester less  than  one-quarter  of  the  total  number  were  over  fifty 
years  of  age,  **  in  marked  contrast  to  the  normal-minded  able- 
bodied  inmates,  the  vast  proportion  of  whom  are  above  that  age." 

With  regard  to  the  employment  of  these  persons,  Dr.  W.  A. 
Potts,  speaking  of  Birmingham,  says  :  "  A  certain  amount  of 
employment  is  found  for  adult  male  defectives,  who  are  taught 
boot-making,  mat-making,  and  rope-making.  Such  work  might 
be  extended  in  this  and  similar  institutions  with  advantage.  It 
is  an  important  proof  of  what  can  be  done  in  workhouses." 
Possibly  the  same  obtains  in  a  few  other  Poor-Law  establishments, 
but  of  the  great  majority  throughout  the  country  it  must  be 
said  that  there  is  very  little  attempt  to  employ  these  persons  to 
any  economic  advantage,  and  I  believe  that  the  conditions  which 
I  found  to  exist  in  Somersetshire  are  very  general.  There  I  found 
that  about  half  the  male  feeble-minded  were  more  or  less  (generally 
less)  usefully  engaged  in  coal-carrying,  wood-chopping,  and  the 
ordinary  domestic  work  of  the  institution,  whilst  about  two-thirds 
of  the  females  were  doing  a  little  scrubbing,  mending,  and  laundry 
work.  The  remainder  were  idle,  and  simply  loafed  about,  many 
of  them  being  either  incorrigbly  lazy  or  requiring  so  much  super- 
vision that  they  were  more  bother  than  they  were  worth. 

In  fact,  the  presence  of  such  a  large  proportion  of  feeble-minded 
persons  in  workhouses  is  not  due  to  any  definite  administrative 
attempt  to  provide  for  this  class,  or  even  to  the  suitability  of 
these  institutions.  It  is  solely  and  simply  a  result  of  the  inevitable 
tendency  for  the  non-supervised  ament  to  drift  out  of  life's  stream 
into  the  nearest  backwater.  I  calculate  that  about  18  per  cent, 
of  the  workhouse  inmates  of  this  country  are  feeble-minded. 

Similarly  with  those  in  receipt  of  outdoor  rehef  :  most  of  them 
are  young  adults,  and  although  a  percentage  are  doing  work 
which  contributes  to  their  support,  there  is  no  doubt  that  under 
a  proper  system  they  might  be  employed  to  much  greater  advan- 
tage. Less  than  one-fourth  of  those  in  Manchester  were  usefully 
employed  ;  in  the  country  districts,  however,  where  work  of  a 


284  Mental   Deficiency 

character  more  suited  to  the  capacity  of  these  persons  is  available, 
from  one-half  to  two-thirds  manage  to  earn  a  little.  The  weekly 
allowance  which  these  defectives  receive  from  the  parish  varies 
very  greatly  in  the  different  unions  ;  on  the  average  it  is  probably 
about  two  shillings  or  half  a  crown,  and  with  this  and  the  shilling 
or  so  they  earn,  supplemented  by  an  occasional  gift  of  boots  or 
cast-off  clothes,  they  manage  to  exist  tolerably  well  as  long  as 
they  have  some  one  to  provide  them  with  shelter,  and  generally 
take  care  of  them.  When  their  protectors  die,  the  refuge  of  all 
these  persons  will  be  the  workhouse. 

The  fact  that  10  per  cent,  of  feeble-minded  persons  are  resident 
in  lunatic  asylums  is  an  indication  of  the  mental  instability,  as 
well  as  deficiency,  of  this  class.  For  the  incarceration  of  practi- 
cally all  of  them  is  due  to  insanity  or  epilepsy. 

It  is  apparent  from  these  inquiries,  that  not  only  do  a  larger 
proportion  of  town  than  country  defectives  receive  Poor-Law  relief, 
but  that  both  absolutely  and  relatively  far  more  are  relieved  in 
the  House.  It  is  to  be  remembered  that  these  remarks  relate  to 
the  feeble-minded  degree  of  defect  only,  a  class  which  is  defined 
as  being  "  capable  of  earning  a  living  under  favourable  circum- 
stances." The  facts  are  sufficient  evidence  as  to  how  little  favour- 
able the  actual  circumstances  at  present  are,  and  it  may  be  re- 
marked that  not  a  few  of  these  feeble-minded  paupers  have  been 
educated  at  great  cost  in  special  schools.  How  illogical  is  the 
system  which  spends  thousands  upon  the  training  of  mentally 
defective  children,  and  then  turns  them  adrift  to  shift  for  them- 
selves as  best  they  can  ! 

Idiots  and  Imbeciles. — Of  the  idiots  and  imbeciles  about  54  per 
cent,  are  paupers,  of  whom  about  two-thirds  are  in  institutions, 
and  one-third  in  receipt  of  outdoor  relief.  Of  those  in  institu- 
tions, nearly  two-thirds  are  in  idiot  or  lunatic  asylums,  and  the 
remainder  in  the  workhouse.  There  is  no  doubt,  however,  that  a 
considerable  number  of  the  imbeciles  at  present  attending  ele- 
mentary schools  (where  they  learn  nothing,  and  are  often  a  con- 
siderable annoyance  and  distraction  to  teachers  and  scholars 
ahke)  will  eventually  become  a  charge  upon  the  rates,  whilst  a 
large  proportion  of  those  not  at  present  in  receipt  of  relief  will 
need  provision  upon  the  death  of  their  parents. 

With  regard  to  the  granting  of  relief  to  idiots  and  imbeciles,  it  is 


The  Ament  and  Society — Pauper  Aments      285 

interesting  to  notice  the  difference  of  method  between  town  and 
country  districts  respectively.  The  proportion  actually  reUeved 
in  the  two  situations  is  pretty  much  the  same  ;  but  whereas  in  the 
towns  36  per  cent,  are  in  the  workhouse  and  7  per  cent,  outside, 
in  the  country  there  are  but  14  per  cent,  ifi  the  house,  as  against 
32  per  cent,  receiving  outdoor  relief. 

Vagrancy. — We  may  now  consider  this  question.  Many  feeble- 
minded persons,  with  a  home  to  which  they  can  turn,  have  such 
a  propensity  for  wandering  that  they  will  roam  the  country  for 
miles  round,  and  sometimes  be  away  for  days  together.  These  are 
often  well  known  to  all  the  country-side,  and  they  frequently  get 
a  plate  of  food  and  a  shakedown  in  the  barn  of  some  hospitable 
farmer  ;  failing  that,  they  spend  the  night  in  a  dry  ditch.  I  do 
not  think  they  ever  have  any  definite  objective  ;  they  simply 
ramble  on  where  the  fit  takes  them.  I  remember  once  pursuing 
one  of  these  youths,  whom  I  particularly  wanted  to  find,  for  a 
whole  day.  I  got  scent  of  him  from  time  to  time,  but,  although  I 
was  driving  and  he  was  on  foot,  it  was  nightfall  before  I  overtook 
him,  and  he  must  have  walked  at  least  twenty  miles. 

On  the  other  hand,  a  small  number  have  no  permanent  home, 
but  simply  shift  for  themselves  as  best  they  may,  and  these, 
perhaps,  are  more  properly  called  vagrants.  As  a  rule,  they  are  the 
least  defective  members  of  the  feeble-minded,  and  although  the 
bulk  of  them  drift  into  the  workhouse  sooner  or  later,  they  do  for 
a  time,  particularly  in  the  country,  manage  to  exist  by  their  wits. 
How  this  is  accomplished  can  generally  only  be  conjectured; 
many  of  them  seem  to  be  itinerant  vendors  of  something  or  other, 
and  no  doubt  they  often  get  a  free  meal  or  cast-off  suit  of  clothes 
given  to  them,  faihng  which  they  are  not  averse  to  begging. 
Some  years  ago  I  used  constantly  to  meet  a  feeble-minded  couple 
of  this  description — ^man  and  wife — who  roamed  the  country  col- 
lecting rags,  bones,  rabbit -skins,  and  such-hke.  But  my  inquiries 
showed  that  their  defect  gave  them  an  unfair  advantage  over 
their  normal-witted  competitors,  inasmuch  as  compassion  gained 
for  them  what  money  had  to  procure  for  the  others,  and  this  is 
probably  the  case  with  most  of  the  feeble-minded  Hving  by  their 
wits.  A  few  of  these  persons  manage  to  earn  enough  to  pay  for 
bed  and  breakfast  in  a  common  lodging-house  ;  these,  however, 
are  the  elite,  and  the  majority  either  sleep  "  rough  "  or  get  a  bed 


286 


Mental  Deficiency 


in  the  casual  ward.  The  inquiries  of  the  Royal  Commission  show 
that  on  the  whole  about  lo  per  cent,  of  the  feeble-minded  come 
within  the  category  of  vagrants,  whilst  about  lo  per  cent,  of  all 
vagrants  are  feeble-minded.  For  the  most  part  I  think  they  are 
well-behaved  and  inoffensive,  but  some  have  decided  insane  or 
criminal  tendencies  and  such  are  an  undoubted  menace  to  society. 
I  have  already  remarked  that  competition  is  much  more  adverse 
to  the  feeble-minded  in  the  towTis  than  in  the  country,  and  that 
in  consequence  a  larger  proportion  of  them  gravitate  into  institu- 
tions. This  is  well  sho^vTl  by  the  following  table  which  I  have 
compiled  from  the  Royal  Commission  Reports  : 

TABLE  XVI. 

Showing  the  Location  of  Feeble-minded  in  Urban  and  Rural 
Areas  Respectively. 


Aments  under  Inadequate  Care. 

By  no  means  one  of  the  least  important  of  the  facts  ascer- 
tained by  the  Royal  Commission  is  the  number  of  aments,  in  the 
eleven  areas  examined,  whose  care  and  control  is  inadequate, 
and  for  whom  further  provision  is  needed,  either  (i)  in  the 
interests  of  the  patients  themselves,  or  (2)  for  the  public  safety. 
The  former  group  consists  of  persons  who,  in  the  opinion  of  the 
respective  investigators,  are  unsuitably  or  unkindly  cared  for  ; 

*  Owing  to  difficulty  of  investigation,  this  class  is  probably  understated. 


The  Ament  and  Society — Pauper  Aments     287 

the  latter,  of  aments  possessing  habits  and  propensities  which 
render  them  a  source  of  danger  to  the  community  in  which 
they  Hve.  It  was  recognized  that  many  persons  might  be  Hving 
under  conditions  which  were  not  ideal,  but  these  are  not  in- 
cluded, the  object  being  to  ascertain  the  irreducible  minimum  in 
urgent  need  of  provision  at  the  present  time.  I  propose  to  quote 
these  figures  as  affording  statistical  proof  of  the  extremely  un- 
satisfactory relationship  at  present  existing  between  the  ament 
and  society. 

In  column  2  of  the  following  table  is  shown  the  percentage  of 
persons  suffering  from  each  of  the  three  degrees  of  defect  who 
were  found  to  be  inadequately  cared  for  in  the  areas  examined. 
There  is  no  reason  for  thinking  that  these  results  are  other  than 
typical  of  the  entire  country  ;  column  3  therefore  shows  the 
estimated  total  number  of  these  persons  in  England  and  Wales.* 


TABLE   XVII. 
Aments  Inadequately  Cared  for. 


Degree  of  Defect. 

Percentage  inadequately 

cared  for  to  Total 

Number  in  Eleven 

A  reas  investigated  by 

Royal  Commission. 

Estimated  Total 
Number  inadequately 

cared  for  in 
England  and  Wales. 

Idiots 

Imbeciles 
Feeble-minded  persons 

40- 8  per  cent. 

462 

31-8        .. 

2,3«I 

7.689 
15.793 

It  is  of  interest  to  note  the  chief  locations  of  these  persons 
needing  further  provision.  In  the  case  of  the  feeble-minded,  the 
highest  proportion  of  those  unsatisfactorily  provided  for  occurs 
in  the  classes  at  large  and  in  charitable  institutions,  in  which 
situations  between  40  and  50  per  cent,  require  further  care. 
With  regard  to  those  at  large  this  high  proportion  is  not  sur- 
prising, but  a  word  of  explanation  is  necessary  in  the  case  of  the 

*  This  estimate  is  calculated  from  the  total  number  of  aments  existing 
in  the  country,  as  ascertained  by  the  method  described  in  Appendix  II.. 
p.  366.  It  does  not  include  Feeble-Minded  ("Mentally  Deficient") 
Children,  who,  according  to  the  Report  of  the  Royal  Commission,  number 
35,662,  or  o"59  per  cent,  of  the  children  on  the  school  register. 


288  Mental   Deficiency 

charitable  homes.  The  high  proportion  here  is  not  any  reflection 
upon  these  homes,  but  is  simply  due  to  the  fact  that  their  provision 
is  temporary  and  optional  only,  and  that  most  of  the  inmates 
are  feeble-minded  girls  who  have  given  birth  to  children.  It  is 
obvious  that  in  the  case  of  such  persons  detention  should  be 
permanent  and  compulsory.  About  one-fifth  of  the  feeble-minded 
in  workhouses,  and  one-fourth  of  those  in  receipt  of  outdoor  relief, 
are  reported  to  be  unsatisfactorily  provided  for. 

Of  the  idiots  and  imbeciles,  the  greatest  proportion  in  need  of 
provision  occurs  amongst  those  receiving  outdoor  relief.  In 
two-thirds  of  these  the  present  conditions  are  so  unsatisfactory 
as  to  urgently  call  for  amendment,  and  nearly  all  of  these  are  in 
rural  districts.  Of  those  at  large  in  fairly  well-to-do  circumstances, 
one-quarter  require  further  care  or  control ;  whilst  of  those  at 
large  who  are  the  offspring  of  the  labouring  class,  the  present 
provision  is  unsatisfactory  in  one-half.  There  can  be  no  doubt 
that  the  presence  of  these  persons  in  small  and  often  overcrowded 
cottages  is  fraught  with  considerable  possibilities  of  harm.  But 
even  apart  from  actual  danger,  want  of  time  and  want  of  know- 
ledge on  the  part  of  the  parents  must  prevent  the  imbecile  or 
idiot  receiving  the  attention  he  needs,  and  which  he  would  obtain 
in  an  institution  ;  whilst  his  presence  cannot  be  regarded  as  con- 
ducive to  the  comfort  of  the  home.  As  far  as  the  idiots  and 
imbeciles  themselves  are  concerned,  the  accommodation  provided 
by  the  workhouses  is  tolerably  satisfactory  ;  it  is  rarely,  however, 
that  any  special  wards  exist  for  them,  and  it  must  be  admitted 
that  the  other  inmates  often  view  the  question  in  a  somewhat 
different  light. 

Propagation  by  Aments. 

There  is  no  law  in  this  country  to  prevent  the  marriage  of  the 
mentally  defective,  and  every  one  knows  that  they  do  marry  and 
have  children.  It  is  also  equally  well  known  that  mentally 
deficient  women  not  infrequently  give  birth  to  illegitimate 
children  ;  but,  as  far  as  I  am  aware,  until  recent  years  there  has 
been  little  definite  inquiry  made  into  this  subject,  and  no  sufficient 
data  upon  which  to  form  any  opinion  as  to  the  frequency  of  this 
evil.  Some  particulars  ascertained  by  the  investigations  of  the 
Royal  Commission  now  throw  a  lurid  glare  upon  the  subject. 


The  Ament  and  Society — Pauper  Aments     289 

They  relate  entirely  to  feeble-minded  females,  and  chiefly  to 
inmates  of  workhouse  maternity  wards. 

In  Manchester,  Dr.  Melland  found  that,  out  of  94  women  in  these 
wards,  19  were  feeble-minded,  all  the  children  except  two  being 
illegitimate.  On  making  further  inquiries  of  some  of  the  younger 
of  the  other  167  feeble-minded  women  in  the  house,  it  was  ascer- 
tained that  another  13  admitted  having  given  birth  to  illegitimate 
children,  and  Dr.  Melland  states  that  these  inquiries  were  only  of 
a  partial  and  incomplete  nature. 

In  Birmingham,  Dr.  Potts  found  that  4  out  of  the  34  women  in 
the  maternity  wards  were  mentally  defective,  whilst  at  Stoke-on- 
Trent  the  same  observer  found  that,  of  the  17  women  giving  birth 
to  children  during  the  period  of  inquiry,  7  were  feeble-minded,  all 
the  children  being  illegitimate.  Dr.  Potts  ascertained  that  the 
total  progeny  resulting  from  16  mentally  defective  women  was  no 
less  than  116.  In  the  lock  wards  he  found  5  feeble-minded  women, 
all  of  whom  were  prostitutes. 

In  the  rural  districts  the  state  of  affairs  was  even  worse.  In 
Wiltshire,  Dr.  Pearse  found  that,  of  58  feeble-minded  women  in 
the  workhouse,  18  had  given  birth  to  illegitimate  children. 
In  Nottinghamshire,  Dr.  Gill  ascertained  that  11  out  of  23  of 
these  women  had  borne  illegitimate  children.  In  Carnarvon, 
Dr.  Parry  found  that  half  the  inmates  of  the  maternity  wards 
were  mentally  defective,  nearly  all  the  children  being  illegitimate  ; 
whilst  in  Somersetshire  I  ascertained  that  fully  half  of  the  women 
admitted  into  the  workhouse  to  be  confined  during  the  previous 
five  years  had  been  feeble-minded  ;  further,  that  out  of  all  the 
feeble-minded  women  in  the  area  (167),  nearly  two-fifths  (61)  had 
given  birth  to  children,  two-thirds  of  whom  were  illegitimate. 

In  few  cases  is  the  propagation  by  these  women  limited  to  a 
single  child.  More  often  their  offspring  number  three  or  four, 
and  one  woman  had  given  birth  to  six  illegitimate  children.  All 
of  these  were  by  different  fathers,  and  she  was  confined  of  each 
one  in  the  workhouse.  I  may  add  that  I  discovered  one  feeble- 
minded woman  in  a  workhouse  who  had  given  birth  to  four 
illegitimate  children,  although  she  had  never  left  the  precincts  of 
the  house. 

When  it  is  remembered  that  these  figures  only  relate  to  a  rela- 
tively small  portion  of  the  country,  and  that  the  investigations 

19 


290  Mental  Deficiency 

only  extended  over  a  period  of  about  three  months,  it  is  clear  that 
the  number  of  children  produced  every  year  throughout  England 
and  Wales  by  feeble-minded  women  must  be  very  great.  In  some 
cases  the  mothers  have  pronounced  erotic  tendencies,  and  many 
of  them  seem  to  be  utterly  lacking  in  any  sense  of  shame,  modesty, 
or  even  ordinary  decency  ;  but  even  the  best-behaved,  and  those 
of  good  parentage  brought  up  amid  every  refinement,  are  often  so 
facile  that  it  is  utterly  unsafe  for  them  to  be  at  large  without 
protection. 

To  the  above  may  be  added  a  statement  by  Dr.  Ireland,  to  the 
effect  that  the  Scottish  Lunacy  Commissioners  in  their  Report  for 
the  year  1857,  "  ascertained  that  the  number  of  idiotic  women  who 
have  borne  illegitimate  children,  and  whose  mental  defect  is  fre- 
quently manifested  in  their  offspring,  was  no  less  than  126,  and  the 
return  was  not  believed  to  be  complete.  Among  the  paupers  in  the 
parish  of  Kintore  there  was  a  fatuous  mother  with  her  two  fatuous 
children.  In  the  parish  of  Latheron,  in  Caithness,  five  imbecile 
females  were  named  as  having  become  mothers.  The  largest 
number  of  children  anywhere  returned  to  one  fatuous  female  was 
five,  the  mother  being  an  idiot  belonging  to  the  parish  of  Erskine, 
in  Renfrewshire." 

As  bearing  on  the  same  question,  I  may  cite  some  returns 
obtained  by  the  Preventive  Committee  of  the  National  Vigilance 
Society.  As  a  result  of  special  inquiries  of  203  Boards  of 
Guardians,  it  was  found  that,  during  the  year  1889,  715  weak- 
minded  women  passed  through  105  workhouses,  whilst  at  56 
workhouses  it  was  stated  that  the  approximate  number  of  such 
women  who  were  leading  immoral  lives  was  366. 

With  regard  to  the  children  of  these  mentally  deficient  women, 
it  would,  of  course,  be  of  the  greatest  interest  and  importance 
to  know  what  becomes  of  them.  Unfortunately,  particulars  of 
this  kind  are  very  difficult  to  obtain,  and  definite  information 
is  in  consequence  very  scanty.  I  may  state  the  following  facts 
which  were  ascertained  by  myself  :  Of  the  61  feeble-minded 
mothers  whom  I  saw  in  Somersetshire,  19  were  married  and  42 
unmarried.  The  19  married  have  produced  a  total  of  80  children. 
Of  these,  16  died  in  infancy,  19  are  imbecile  or  feeble-minded, 
20  are  either  physically  delicate  to  a  pronounced  degree  or  are 
mentally  dull  and  backward,  whilst  8  are  too  young  to  satis- 


1 


The  Ament  and  Society — Pauper  Aments     291 

factorily  examine.  There  are  only  17  out  of  the  total  80  who 
appear  to  come  up  to  the  average  standard  of  mental  and  bodily 
health.  With  regard  to  the  illegitimate  children,  the  particulars 
ar^  of  necessity  less  complete.  The  42  mothers  have  produced  78 
children.  Of  these,  24  died  in  infancy,  5  are  imbecile  or  feeble- 
minded, 2  are  markedly  dull  and  backward,  2  appear  to  be 
normal,  and  the  remaining  45  have  been  completely  lost  sight  of. 
It  must  be  remembered  that  in  practically  all  these  cases  infor- 
mation as  to  the  paternal  inheritance  of  these  children  is  un- 
obtainable. 

As  bearing  upon  the  questions  of  propagations  and  the  social 
relationship  of  the  ament, ,  I  may  cite  the  following  cases  which 
have  recently  come  within  my  experience : 

Upon  the  edge  of  a  moor,  in  a  thinly  inhabited  part  of  the 
West  Country,  stands  a  filthy  thatched  wooden  hovel  consisting 
of  two  rooms.  Its  exterior  has  an  air  of  utter  desolation  and 
neglect ;  its  interior  is  in  a  state  of  indescribable  dirt  and  con- 
fusion. It  is  occupied  by  a  married  couple  and  their  family.  The 
man,  aged  fifty  years,  is  of  a  decidedly  low  animal  type,  and  has 
considerable  moral,  as  well  as  shght  mental,  defect.  He  never 
refuses  a  drink,  and  picks  up  a  living  by  occasional  osier-stripping, 
and  doing  odd  jobs  on  farms,  but  chiefly,  I  think,  by  poaching. 
The  woman,  his  wife,  is  forty-four  years  of  age  and  feeble- 
minded. She  seems  to  be  busy  most  of  the  day,  and  in  her  way 
keeps  the  house  going  ;  but  she  is  utterly  lacking  in  any  capacity 
for  management,  and  the  filth  and  disorder  are  extreme.  This 
woman  had  three  children  before  marriage,  and  nine  since.  Of  the 
[former  three,  one  died  young  of  consumption,  a  second  has 
^entirely  disappeared,  and  the  third  Hves  about  the  neighbourhood ; 
[but  he  quarrelled  with  his  mother's  husband,  and  they  are  not 
now  on  speaking  terms.  Of  the  nine  born  in  wedlock,  two  died  in 
[infancy,  three  attend  the  village  school  and  are  mentally  defective, 
land  another  also  mentally  defective  is  at  home.  The  eldest  does 
I  odd  jobs  with  his  father,  and  seems  to  be  able  to  take  care  of 
himself.  The  remaining  two  are  aged  five  months  and  three  years 
! respectively,  and  are  too  young  to  enable  an  opinion  to  be  formed 
as  to  their  mental  capacity.  To  this  it  may  be  added  that  the 
father  has  had  ten  children  by  a  previous  wife.  Of  these,  two  are 
feeble-minded,  one  of  whom  is  living  a  life  of  prostitution,  and 

19 — 2 


292  Mental   Deficiency 

has  already  had  two  illegitimate  children  in  the  workhouse.  The 
others  have  been  entirely  lost  sight  of. 

Mary  H is  a  feeble-minded  married  woman  forty  years  old. 

She  lives  with  her  husband,  a  farm  labourer,  in  a  small  cottage  in 
an  isolated  village.  She  is  industrious  and  always  working, 
but  the  house  is  in  a  disgraceful  muddle.  At  my  visit  there 
were  two  unwashed,  partially  dressed  children,  under  three  years 
of  age,  sprawling  about  the  wet  stone  floor  amid  a  litter  of  dirty 
plates  and  pans,  potato  peelings,  and  live  poultry.  Upon  asking 
her  how  old  she  was,  and  how  long  she  had  been  married,  she 
replied,  with  a  fatuous  smile,  that  she  didn't  know,  but  her 
mother  did.  The  children  I  saw  in  the  house  were  too  young  to 
examine  mentally  ;  but  two  other  illegitimate  children  whom  I 
did  see,  aged  sixteen  and  seventeen  years  respectively,  were 
feeble-minded.  Both  of  these  are  industrious  boys,  and  work  well 
under  supervision,  but  they  are  quite  incapable  of  looking  after 
their  affairs.  This  woman  has  two  brothers,  who  are  also  feeble- 
minded ;  one  is  constantly  in  and  out  of  the  workhouse,  but  the 
other,  aged  thirty,  is  employed  regularly  with  a  farmer  at  the 
rate  of  a  shilling  a  day.  Their  mother  has  had  several  attacks  of 
insanity,  but  the  father  is  dead,  and  no  particulars  were  obtain- 
able regarding  him. 

Rose  D is  a  feeble-minded  woman  forty-five  years  of  age. 

She  is  the  daughter  a  of  well-to-do  farmer,  but  ran  away  from 
home  at  the  age  of  twenty  years,  and  since  then  she  has  been 
living  a  hfe  of  prostitution.  Her  usual  abode  is  the  common 
lodging-house,  but  a  considerable  part  of  her  life  has  been  spent 
in  prison,  the  workhouse,  and  various  charitable  homes.  She  has 
been  confined  of  three  illegitimate  children  in  the  workhouse. 
The  clergyman  of  the  parish  in  which  she  lives  says  that  he  has 
got  her  into  homes  again  and  again,  but  she  will  not  stay,  and 
they  cannot  compel  her  to  do  so.  All  attempts  to  induce  her 
to  lead  a  respectable  life  have  failed,  and  she  is  his  despair  and 
a  disgrace  to  the  civilization  which  permits  her  to  be  at  large. 

I  may  add  that  these  are  by  no  means  isolated  instances. 
Many  of  the  particulars  regarding  this  matter  which  have  come 
under  my  own  notice  are  too  revolting  for  publication,  and  there 
is  the  clearest  evidence  that  the  propagation  by  aments  is  both 
a  terrible  and  extensive  evil. 


CHAPTER  XVI 

MORAL  DEFICIENCY  AND  CRIMINAL  AMENTS 

The  subject  of  moral  deficiency  is  one  of  extreme  interest  alike 
to  the  alienist  and  criminologist,  and  although  some  persons 
would  be  inclined  to  look  upon  the  moral  or  ethical  sense  as 
transcending  mind  altogether,  it  is,  nevertheless,  so  clearly  an 
integral  part  of  that  complex  sum  of  processes  to  which  we  give 
the  name  mind  that  the  question  of  moral  deficiency  cannot  be 
ignored  in  a  work  dealing  with  amentia. 

But  although  the  moral  sense  is  unquestionably  part  of  the 

mt  ensemble  of  mind,  it  does  not  follow  that  the  person  in  whom 

it  is  defective  is  necessarily  an  ament.     There  are  four  chief 

senses  "  or  "  sentiments  "  which,  in  varying  proportions,  go 
to  make  up  the  mind  of  average  civilized  man.     These  may  be 

|p<;rrjbpj_a5  fhpjo^nrgl  or  intpHprtnal/thf^  religiouvthejesthetic^ 

md  J-.he    moral    or   social.     The   logical    or    intellectual    sense 

causes  us  to  test  each  new  experience  by  the  light  of  our  previous 

:nowledge,  to  criticize  and  carefully  compare,  and  to  accept  or 

reject  according  as  our  judgment  affirms  it  to  be  true  or  untrue. 

1  Such  a  type  of  mind  is  said  to  be  essentially  rational.     The 

•  religious  sense  implies  a  conception  of  the  relationship  between 

I  God  and  man.     It  is  largely  made  up  of  the  emotions  of  awe, 

reverence,  and   adoration^  and  religion  has  been  well  defined 

as  "  The  feeling  of  reverence  which  men  entertain  toward  a 

Supreme  Being,  or  to  any  order  of  beings  conceived  by  them 

as   demanding  reverence   from   the   possession   of   superhuman 

control  over  the  destiny  of  man  or  the  powers  of  nature."*    The^ 

(aesthetic  sense  connotes  a  marked?  appreciation  of  all  that  is 
beautiful  in  form,   colour,  sound,  etc.     Whilst,  lastly,  by  the 
*  Ogilvie  and  Annandale,  "  Imperial  Dictionary." 
293 


294  Mental  Deficiency 

f  moral  sense  is  meant  the  faculty  of  appreciating  the  obligations 

i  due  from  man  to  his  neighbours  as  component  units  of  society. 
Now,  these  various  senses  are  differently  developed  in  different 
individuals,  and  this  is  partly  a  result  of  special  hereditary 
tendencies,  and  partly  due  to  the  nature  of  the  early  environment. 
Some  persons  are  full  of  religious  and  moral  feeling  (although 
the  two  are  by  no  means  synonymous),  and  yet  absolutely 
illogical  and  inartistic.  Others,  of  extreme  aesthetic  develop- 
ment, have  no  sense  of  logic  ;  whilst  yet  others,  of  the  keenest 
intellect  and  highest  logical  capacity,  are  devoid  of  moral  con- 
sciousness. The  mind  of  the  child  is  usually  deficient  in  this 
latter  sense,  and  it  is  only  by  the  constant  force  of  example,  the 
reiteration  of  precept,  and  perhaps  the  infliction  of  punishment, 
that  it  learns  to  think  and  act  according  to  the  stereotyped  social 
and  legal  code  of  the  age  to  which  it  belongs,  and  so  conforms 
to  moral  and  social  law. 

Although  human  conceptions  of  morality,  as  also  of  religion 
and  art,  are  ever  changing  with  social  development  and  the 
progressive  evolution  of  the  mental  faculties,  there  is  every 
reason  for  thinking  that  some  persons  are  so  constituted  that 
they  are  utterly  devoid  of  any  real  moral  sense,  and  of  the 
consciousness  that  any  obligation  is  morally  due  from  them  to 
their  fellows  ;  just  as  others  may  have  no  sense  of  religion  or 
no  conception  of  the  beauties  of  form,  colour,  or  sound.  Such 
defect  is  inherent,  and  it  may  rightly  be  called  moral  deficiency. 

Its  relation  to  criminality,  however,  is  another  matter.  It 
may  be  that,  although  these  persons  have  no  feelings  of  repug- 
nance or  shame  at  the  thought  of  a  criminal  or  immoral  act,  and 
although  they  cannot  appreciate  the  ethics  of  the  Decalogue, 
nevertheless  their  intelligence  tells  them  that  certain  unpleasant 
consequences,  in  the  shape  of  judicial  punishment  or  social 
censure,  will  follow  transgression,  and  this  suffices  to  keep  them 

'  within  the  prescribed  legal  and  social  code.     Their  moral  defect 

i  is,  in  fact,  latent. 

It  is  the  same  with  the  aesthetic  and  religious  senses.  Many 
persons  utterly  devoid  of  conceptions  of  beauty  or  harmony 
still  manage  to  avoid  running  counter  to  the  canons  of  good 
taste  by  conforming  to  the  recognized  customs  of  society,  and 
how' many  who  are  absolutely  wanting  in  any  real  religious  feeling 


Moral  Deficiency  and  Criminal  Aments     295 

acquire  a  reputation  for  piety  and  reverence  as  a  result  of  their 
scrupulous  observance  of  religious  form  and  ceremony  ! 

But  although  latent  moral  defectives  of  this  kind  are  not  of  \ 
necessity  actual  criminals,  they  may  well  be  described  as  potential  ;\ 
criminals.  They  stand  in  the  same  relation  to  the  inmates  of  our 
prisons  as  do  the  psychopaths  or  potential  lunatics  to  the  inmates 
of  our  asylums,  or  the  improvident  to  the  inmates  of  our  work- 
houses, and  there  can  be  no  doubt  that  it  is  from  this  class  that 
one  section  of  our  criminals  is  drawn.  Although  there  is  no 
intellectual  defect,  and  such  persons  fully  realize  the  conse- 
quences of  detection,  yet  occasionally  the  gain  resulting  from  a 
crime  or  act  of  immorality  appears  so  great,  and  the  likelihood 
of  discovery  so  small,  that,  moral  sense  being  absent,  they  deliber- 
ately take  the  riskT^  Since,  however,  our  standard  of  mind  is  an 
intellectual  one,  such  persons  can  no  more  be  considered  as 
mentally  deficient  than  can  those  who  are  lacking  in  the  religious 
or  aesthetic  sense. 

But  the  case  is  different  with  another  class.  There  are  some  . 
persons,  likewise  deficient  in  moral  sense,  who  repeatedly  commit 
criminal  acts,  and  upon  whom  punishment  has  not  the  slightest 
deterrent  effect  whatever.  These  form  a  large  proportion  of 
the  instinctive  or  habitual  criminal  class,  the  true  moral  defec- 
tives, and  they  may  be  defined  as  "  those  persons  who  display 
from  an  early  age,  and  in  spite  of  careful  upbringing,  strong 
vicious  or  criminal  propensities  on  which  punishment  has  little 
or  no  deterrent  effect."  ^ 

As  to  whether  the  members  of  this  class  are  or  are  not  intel- 
lectually deficient,  opinions  differ.  It  it  contended  by  some  that 
such  a  propensity  to  crime  may  exist  without  any  intellectual 
defect,  whilst  others  maintain  that  a  deficiency  of  the  intellectual 
faculty  is  also  present — that,  in  fact,  such  persons  are  aments. 
The  question  is  one  which  it  is  extremely  difficult  to  decide.  On 
the  one  hand  there  is  no  doubt  that,  although  many  of  these 
persons  commit  offences  in  the  most  open  manner,  and  from 
which  they  have  nothing  to  gain,  yet  they  will  converse  upon 
many  subjects  in  an  exceedingly  intelligent  way,  whilst  some 
are  actually  possessed  of  unusual  talents.  A  few  again,  in  their 
commission  of  offences  and  their  attempts  to  escape  detection, 
show  a  capacity,  alertness,  and  cunning,  of  a  very  high  order,  and 


296  Mental  Deficiency 

which  also  would  seem  to  be  incompatible  with  the  presence 
of  amentia.  On  the  other  hand,  however,  their,  utter  inability 
to  keep  within  the  law  and  to  control  their  evil  propensities, 
when  they  know  that  punishment  has  followed,  and  will  almost 
inevitably  follow  again,  is  certainly  suggestive  of  a  deficiency  of 
intellect,  or,  at  any  rate,  of  a  defective  power  of  self-control. 

As  tending  to  elucidate  this  question,  we  may  refer  to  the 
many  characteristics  which  these  persons  possess  in  common 
with  aments.  During  rece.nt  years  numerous  investigations  have 
been  carried  out  in  England,  America,  Italy,  France,  Germany, 
and  Russia  with  regard  to  the  physical  and  psychological  features 
of  the  habitual  or  instinctive  criminal  class,  and  of  which  many 
particulars  are  given  in  Havelock  Ellis's  most  interesting  book 
"  The  Criminal."     To  some  of  these  we  may  refer. 

With  regard  to  the  brain,  the  results  do  not  enable  one  to 
say  that  a  special  "  criminal  type  "  exists,  but  nearly  all  the 
inquirers  are  agreed  that  anatomical  anomalies  indicative  of 
arrested  development  are  of  much  more  common  occurrence 
than  in  the  normal  population.  The  same  is  true  of  the  face, 
jaws,  palate,  and  body  generally ;  in  the  habitual  criminal 
stigmata  of  degeneracy  abound  just  as  they  do  in  the  ament. 
The  Anthropometric  Committee  of  the  British  Association 
examined  over  3,000  criminals,  and  found  them  about  2  inches 
shorter  and  17  pounds  lighter  than  the  average  English  population. 
Baer  examined  4,500  Berlin  criminals,  and  found  that  the  average 
height  was  decidedly  below  the  normal,  and  the  same  was 
observed  by  Hamilton  Wey  in  America.  Dr.  G.  Wilson,  in  a 
paper  on  "  The  Moral  Imbecility  of  Habitual  Criminals  as 
Exemplified  by  Cranial  Measurements,"*  arrived  at  the  conclu- 
sion, from  measurements  of  the  heads  of  464  criminals,  that 
habitual  thieves  had  well-marked  indications  of  defective  cranial 
development  associated  with  physical  deterioration.  Dr.  J. 
Bruce  Thompson,  t  in  a  summary  of  his  observations  upon  over 
5,000  prisoners,  pointed  out  the  great  prevalence  of  mental 
defect,  especially  amongst  the  juvenile  criminals,  and  also  the 
frequency  with  which  morbid  appearances  were  found  post- 
mortem.    Professor  Lombroso,  in   his  book  "  L'  Uomo  Dehn- 

*  A  paper  read  before  the  British  Association  at  Exeter,  1869. 
f  Journal  of  Mental  Science,  1870. 


Plate  XXVI. 


To  face  pds;e  296.] 


Of   THE 

UNIVERSITY 

OF 


Moral  Deficiency  and  Criminal  Aments       297 

quente,"  came  to  the  conclusion,  on  anthropometrical  grounds, 
that  the  criminal  is  a  manifestation  of  degeneracy. 

Similarly  with  mental  characteristics.  Although  many  of  the 
criminal  class  appear  on  casual  examination  to  be  of  average 
intellectual  calibre,  there  is  abundant  evidence  to  show  that  a 
large  number  of  them  present  anomalies  similar  to  those  referred 
to  in  our  description  of  the  Feeble  Mind.  As  Havelock  Ellis 
"says,  "  On  the  one  hand  he  is  stupid,  inexact,  lacking  in  fore- 
thought, astoundingly  imprudent  ;  on  the  other  hand  he  is  cun- 
ning, hypocritical,  delighting  in  falsehood,  even  for  its  own 
sake,  abounding  in  ruses."  And  in  another  place,  "  The  criminal 
in  some  of  his  most  characteristic  manifestations  is  a  congenitally 
weak-minded  person,  whose  abnormality,  whilst  by  no  means 
leaving  the  mental  aptitudes  absolutely  unimpaired,  chiefly 
affects  the  feelings  and  volition,  so  influencing  conduct  and 
rendering  him  an  anti-social  element  in  society."  Dr.  Maudsley,* 
speaking  of  instinctive  criminals,  says  :  "  It  is  a  matter  of  observa- 
tion that  the  criminal  class  constitutes  a  degenerate  or  morbid 
variety  of  mankind  marked  by  peculiarly  low  physical  and 
mental  characteristics  ;"  whilst  Dr.  Nicholsonf  has  also  pointed 
out  the  great  prevalence  of  weak-mindedness,  with  instability, 
tendency  to  delusions,  insensibility,  and  emotional  nature,  in  the 
criminal  class. 

Finally,  the  close  connexion  between  criminals  and  aments 
is  further  shown  by  the  antecedents  of  the  two  classes.  In 
inquiring  into  the  family  histories  of  members  of  the  habitual  crim- 
inal class,  I  have  often  been  struck  by  the  fact  that,  although 
they  themselves  might  show  little  obvious  indication  of  mental 
inferiority,  a  large  number  of  them  came  of  a  neuropathic  stock, 
and  possessed  brothers  and  sisters  who  were  markedly  deficient. 
Conversely,  in  examining  aments,  I  have  often  found  that  their 
brothers  or  sisters  were  criminals.  In  dealing  with  the  inmates 
of  prisons  it  is  often  extremely  difficult  to  obtain  a  family  history, 
but  it  was  ascertained  that,  of  233  prisoners  at  Auburn,  New 
York,  at  least  23  per  cent,  were  of  neurotic  (insane  and  epileptic) 
origin.  Rossi  found  that  in  71  criminals  there  were  5  insane 
parents,  6  insane  brothers  and  sisters,  and  14  cases  of  insanity 

*  Maudsley,  "  Responsibility  in  Mental  Disease,"  1872. 
t  Nicholson,  Journal  of  Mental  Science,  1873-1875. 


298  Mental  Deficiency 

amongst  more  distant  relatives.  Kolk  found  a  morbid  inheritance 
in  46  per  cent,  of  criminals,  and  Marro  in  77  per  cent.  Sichard, 
as  a  result  of  his  examination  of  nearly  4,000  German  criminals, 
found  that  there  was  an  insane,  epileptic,  suicidal,  or  alcoholic 
heredity  in  36*8  per  cent,  of  incendiaries,  32  per  cent,  of  thieves, 
287  per  cent,  of  sexual  offenders,  and  23*6  per  cent,  of  sharpers. 

Lastly,  the  interesting  record  of  the  Juke  family,  which  was 
compiled  by  R.  L.  Dugdale,*  well  shows  the  close  relationship 
existing  between  the  criminal  and  the  psychopath.  This  observer 
traced  the  descendants  of  one  morbid  couple  through  five  genera- 
tions to  the  number  of  709  individuals,  and  found  that  whilst  a 
small  proportion  were  honest  workers,  the  great  majority  were 
vagabonds,  paupers,  criminals,  and  prostitutes. 

I  think  these  facts  (and  I  have  only  referred  to  a  few  of  them) 
conclusively  show  that,  although  in  a  large  number  of  habitual 
or  instinctive  criminals  the  defect  may  appear  to  be  more  moral 
than  intellectual,  nevertheless  their  persistent  criminality  in 
spite  of  punishment,  as  well  as  the  many  features  they  possess 
in  common  with  the  true  aments,  are  a  sufficient  justification  for 
our  considering  them  as  being  closely  related  to,  if  not  actually 
suffering  from,  a  mild  degree  of  mental  deficiency. 


Criminal  Aments. 

We  may  now  consider  a  somewhat  different  class,  namely, 
persons  suffering  from  undoubted  intellectual  deficiency  who 
have  pronounced  immoral  and  criminal  tendencies,  and  who  are 
in  consequence  guilty  of  repeated  offences  against  law  and  society. 

Such  persons  may  belong  to  any  of  the  three  degrees  of 
amentia.  As  we  have  seen,  idiots  are  often  extremely  destruc- 
tive, and  they  may  commit  homicide.  Many  imbeciles  have 
pronounced  thieving  propensities,  are  guilty  of  incendiarism,  or 
possess  marked  sexual  desires,  which  they  may  forcibly  seek  to 
gratify.  More  commonly,  however,  criminal  aments  belong  to 
the  feeble-minded  or  mildest  degree,  and  this  is  probably  the 
result  of  their  greater  personal  freedom  from  supervision,  as  well 
as  their  numerical  preponderance — perhaps,  also,  partly  owing 
to  their  greater  knowledge. 

*  Putnams,  New  York,  1877. 


Moral  Deficiency  and  Criminal  Aments     299 

Some  idea  of  the  number  of  mentally  deficient  criminals  under 
detention  in  this  country,  and  of  the  general  policy  of  the  Prison 
Commissioners  regarding  them,  will  be  gathered  from  the  reply 
to  a  -question  in  the  House  of  Commons  on  July  22,  1907.  The 
Home  Secretary  said  :  "Both  in  local  and  convict  prisons  those 
prisoners  who  are  not  certifiably  insane,  but  are  unfit  through 
mental  deficiency  for  the  ordinary  penal  discipline,  form  a 
separate  class  and  are  specially  treated.  In  the  year  1906-07 
the  numbers  were  :  the  local  prisons  355,  and  in  convict  prisons 
107.  The  policy  of  the  Prison  Commissioners  is  to  place  these 
prisoners  under  the  special  charge  of  the  medical  officers  of  the 
prisons,  and  to  keep  them  continuously  under  the  personal  care 
of  selected  warders.  The  medical  officers  regulate  their  dis- 
cipline and  diet,  and  allow  them  such  employment  as  is  suited 
to  the  condition  of  each  individual.  In  addition  to  those  so 
classified,  there  are  other  prisoners  temporarily  under  observa- 
tion to  ascertain  their  mental  state." 

The  recent  investigations  of  the  Royal  Commission  show  that 
about  10  per  cent,  of  the  inmates  of  prisons  are  aments.  These 
figures  must  be  considered  rather  to  under-estimate  than  over- 
estimate the  facts,  for  the  uniform  practice  of  the  inquirers  was  to 
include  only  such  cases  as  showed  clear  and  undoubted  signs  of 
mental  defect.  On  the  other  hand,  a  careful  analysis  of  the 
same  inquiries  shows  that  about  10  per  cent,  of  all  feeble-minded 
persons  have  pronounced  criminal  and  antisocial  propensities. 

Feeble-minded  criminals,  using  this  latter  word  in  its  widest 
sense,  fall  into  three  groups.     On  the  one  hand  there  are  those 
who  are  led  into  the  commission  of  offences  against  law  and 
morality  by  reason  of  their  extremely  facile  disposition,  which 
makes  them  ready  tools  in  the  hands  of  evil-doers.   The  deficiency    ^ 
here  is  largely  one  of  control  or  of  knowledge,  and  they  are     -^     jy 
rather   sinned   against  than  sinning.     Our  police-courts  show    \jy\    ^ 
that  feeble-minded  dupes  of  this  kind  are  by  no  means  unknown    ^        <^ 
to-day,  although  it  is  Ukely  that  the  number  of  persons  profiting 
by  this  failing  of  the  mentally  defective  has  been  considerably 
diminished  in  recent  years.     At  the  present  time  it  is  probable 
that  prostitutes   comprise  the  largest^roportion  of  this  type, 
especially  in  our  towns  and  industrial  centres. 

Another  group  of  feeble-minded  persons  are  of  such  an  ex- 


1  ^   - 


300  Mental  Deficiency 

P  citable,  expbsive,  and  generally  unstable  mental  constitution 
as  to  be  utterly  untrustworthy,  and  a  considerable  number  of 
the  offences  against  society  are  committed  by  this  class.  It 
'  may  be  termed  "the  impulsive  type  of  criminal  ament."  Far 
'  from  being  facile,  they  are  generally  extremely  obstinate  and 
intolerant  of  contradiction,  and  they  will  often  suddenly  pass 
from  a  state  of  what  appears  to  be  perfect  calm  and  indifference 
to  one  of  raving,  uncontrollable  fury.  Many  of  them  are  very 
suspicious,  and  some  have  definite  delusions  ;  in  fact,  I  think 
that  all  this  class  have  an  extremely  strong  tendency  to  insanity, 
and  that  often  during  the  commission  of  their  offences  they  are 
actually  insane.  Most,  but  not  all,  are  of  the  mildest  degree 
of  amentia.  In  many  of  their  characteristics  these  persons 
resemble  the  epileptics,  but  I  do  not  think  that  they  commonly 
suffer  from  epilepsy.  The  offences  most  commonly  committed 
are  criminal  and  other  assaults,  acts  of  wanton  destruction, 
cruelty  to  animals,  fighting,  brawling  and  disorderly  conduct. 

Feeble-minded  persons  in  general  are  very  intolerant  of 
alcohol,  but  its  effects  seem  to  be  especially  marked  upon  the 
type  we  are  now  considering.  I  remember  one  youth  in  a  country 
village  who  used  to  be  repeatedly  plied  with  cider  by  the  yokels 
of  the  place  in  order  that  they  might  be  amused  by  his  furious 
excitement,  pretty  much  in  the  same  way  as  a  bull  is  baited  in 
the  ring.     The  following  are  good  examples  of  the  type  : 

Thomas  B ,  a  feeble-minded  young  man,  twenty-five  years 

of  age,  with  numerous  stigmata  of  degeneracy.  He  could  never 
learn  at  school,  and  afterwards  could  not  keep  his  situations. 
At  the  age  of  twenty-three  he  became  insane,  and  was  sent  to 
the  asylum  for  six  months.  Shortly  after  discharge  he  was 
apprehended  for  sleeping  out,  and  served  seven  days'  imprison- 
ment. He  had  only  been  out  a  few  weeks  when  he  attempted 
rape  on  a  small  girl  whom  he  met  in  the  road.  For  this  he  was 
sentenced  to  two  months'  hard  labour.  On  being  liberated  he 
became  very  violent  and  aggressive,  and  threatened  to  cut  his 
mother's  throat.  He  was  again  sent  to  the  asylum,  and  dis- 
charged in  six  months.  He  is  now  living  at  home,  and  works 
occasionally  in  the  factory ;  but  his  mother  says  that  he  cannot  be 
depended  upon,  that  some  days  he  refuses  to  get  out  of  bed,  and 
is  at  times  so  violent  that  she  is  afraid  to  have  him  in  the  house. 


Moral  Deficiency  and  Criminal  Aments        301 

He  is  a  powerful  fellow,  who  should  be  capable  of  hard  work 
could  he  be  controlled. 

Alfred  L ,  a  feeble-minded  man  of  twenty-eight  years.     He 

is  now  occupied  cracking  stones,  and  does  occasional  work  on 
farms  when  he  can  get  it  ;  but  he  is  very  unstable,  at  times  being 
noisy,  excitable,  quarrelsome,  and  absolutely  refusing  to  do  any 
work.  He  has  been  imprisoned  at  least  six  times  for  such 
offences  as  drunkenness,  fighting,  stealing,  and  setting  fire  to  gorse, 
and  is  known  and  dreaded  for  miles  round  as  a  regular  nuisance. 

The  third  group  is,  I  think,  the  most  numerous  of  all,  and  ^ 
consists  of  those  feeble-minded  persons  who  commit  crimes,  not 
under  external  suggestion,  and  not  because  they  are  passionate 
and  excitable,  but  because  either  they  cannot  really  appreciate 
the  difference  between  right  and  wrong  or  have  ineradicable 
and  irresistible  criminal  propensities.  In  fact,  they  suffer,  not 
so  much  from  a  defect  of  inhibition,  as  from  a  pronounced  mental 
and  moral  perversion.  The  crimes  of  these  persons  differ  from 
those  of  the  two  preceding  groups,  inasmuch  as,  although  they 
may  at  times  appear  to  be  sudden  and  unpremeditated,  they 
more  often  show  evidence  of  previous  deliberation  and  plan, 
and  sometimes  of  considerable  cunning  to  escape  detection.  In 
addition  to  persistent  lying,  thieving,  indecency,  acts  of  craelty 
and  wanton  destruction,  these  individuals  are  often  guilty  of  the 
more  serious  crimes  of  incendiarism,  train-wrecking,  criminal 
and  homicidal  assaults. 

It  is  a  remarkable  fact  that,  although  these  persons  whilst  at 
liberty  and  away  from  supervision  seem  absolutely  incapable 
of  conforming  to  the  law,  they  are  nearly  always  quiet  and 
well-behaved  under  the  discipline  of  a  prison.  Their  lives 
consist  of  an  unbroken  series  of  offences,  in  many  cases  there 
being  literally  scores  of  convictions,  whilst  in  some  they  amount 
to  over  a  hundred.  They  are  the  definitely  mentally  defective 
habitual  criminals. 

In  most  of  these  cases  the  condition  is  present  in  childhood, 
and  is  shown  by  habits  of  lying,  thieving,  and  the  like,  upon 
which  punishment  has  not  the  slightest  effect.  I  know  one  boy 
who  has  not  yet  reached  his  eighth  birthday,  but  he  has  already 
been  expelled  from  school  because  nothing  was  safe  within  his 
reach.     He  has  a  vocabulary  equal  to  that  of  any  bargee,  and 


30  2  Mental  Deficiency 

he  steals  eggs,  fruit,  money,  and  anything  he  can  lay  his  hands 
on  ;  he  has  already  burnt  two  hayricks  to  the  ground.  In 
an  elementary  school  of  a  provincial  town  I  came  across  three 
children  of  this  type  belonging  to  one  family.  The  two  boys  were 
only  eight  and  five  years  old  respectively,  and  the  girl  seven 
years  ;  but  the  schoolmaster  told  me  that  they  had  a  propensity 
for  lying,  thieving,  and  causing  trouble  generally,  the  like  of 
which  he  had  never  met,  and  that  nothing  seemed  to  deter  them. 
They  were  all  mentally  defective,  and  I  was  informed  that  the 
father  was  of  the  same  type,  and  more  often  in  than  out  of 
prison.     The  following  cases  are  further  examples  of  this  class  • 

George  P ,  a  mentally  defective  child,  aged  thirteen  and  a 

half  years,  attending  school  in  Standard  I.  Power  of  reasoning 
decidedly  wanting,  but  alert  and  cunning,  and  always  getting 
into  trouble.  He  is  said  to  be  incorrigibly  lazy  at  school,  and 
a  frequent  truant,  and  the  schoolmaster  says  that  he  will 
steal  and  lie  without  the  least  compunction,  and  that  punish- 
ment seems  to  be  without  the  slightest  effect.  He  is  always 
ready  with  a  plausible  excuse,  and  shows  a  precocious  amount  of 
cunning  in  covering  up  "his  misdeeds.  A  short  time  ago  he  stole 
the  schoolmistress's  gold  watch  from  its  accustomed  place  on 
her  desk.  It  was  not  missed  until  the  children  had  left,  and 
then  there  was  an  instant  hue  and  cry.  George,  finding  himself 
pursued,  secreted  the  watch  in  a  tree,  and  then  submitted  himself 
to  be  searched  with  an  air  of  complete  innocence.  Unluckily, 
however,  for  him,  the  manoeuvre  had  been  seen.  It  is  interesting 
to  note  that  this  boy's  father  is  just  the  same  (indeed,  I  am 
inclined  to  think  that  this  moral  perversion  is  generally  heredi- 
tary). He  is  plausible  and  cunning,  and,  although  he  occasionally 
does  odd  jobs,  I  was  told  by  the  poHce  that  he  never  did  any 
regular  work,  and  that  the  greater  part  of  his  life  had  been  spent 
in  prison  for  such  offences  as  stealing,  poaching,  and  drunken- 
ness. When  I  saw  him  he  had  just  returned  from  serving  a 
term  of  imprisonment  for  poaching. 

George  A ,  a  feeble-minded,  undersized  youth  with  a  slouch- 
ing walk,  furtive  demeanour,  and  physiognomy  typical  of  mental 
defect.  He  answers  questions  in  a  simple,  childish  manner, 
and  gives  information  regarding  his  past  life  willingly  and  with- 
out any  appearance  of  shame  or  concern  ;  his  memory,  however, 


Moral  Deficiency  and  Criminal  Aments       303 

is  a  little  defective,  and  his  account  is  at  times  confused  and 
incoherent.  He  cannot  read,  write,  or  sum,  but  he  is  quite 
capable  of  useful  work  under  supervision,  and  his  conduct  in 
prison  (where  I  saw  him)  is  good.  The  youth  knows  nothing 
about  his  parents,  and  little  about  his  early  life  beyond  the  fact 
that  he  was  brought  up  in  an  industrial  school,  and  thence  put 
to  work  on  a  farm.  He  ran  away  because  he  wanted  a  change, 
and,  after  tramping  about  for  a  time,  eventually  got  employment 
on  another  farm.  He  ran  away  from  here  because  he  was 
discovered  committing  acts  of  indecency  with  the  cattle.  He 
then  tramped  about,  and  was  frequently  in  and  out  of  work- 
houses. He  was  convicted  with  several  others  of  stealing  lead, 
and  served  a  term  of  imprisonment.  After  this  he  again  tramped 
the  country,  spending  most  of  his  time  between  the  prison  and 
the  workhouse.  He  is  now  in  for  setting  fire  to  a  rick,  for 
which  act  he  is  unable  to  give  any  reason. 

Finally,  as  further  examples,  I  may  refer  to  the  following  four 
cases  culled  from  the  newspapers  during  the  past  few  months, 
all  of  which  were  reported  to  be  mentally  defective. 

"  W.  K.,  a,  ten-year-old  boy,  was  charged  at  Bow  Street  with 
attempted  pocket-picking  in  a  railway- train.  The  boy  excused 
himself  by  saying  that  his  mother  had  pushed  him  into  the 
train  with  orders  to  rob  the  lady.  The  police  found  that  there 
was  not  a  tittle  of  evidence  to  support  the  lad's  statement, 
and  an  officer  from  the  school  board  reported  that  he  was 
mentally  defective." 

''  H.A.,s.  feeble-minded  deaf-mute,  was  charged  with  stabbing 
his  sister.  The  prosecutrix  said  that  he  had  never  been  quite 
right  in  his  mind,  and  that  she  had  always  treated  him  as  a  child, 
but  that  he  was  no  trouble  if  he  did  not  get  into  drink.  The 
medical  officer  of  the  prison  certified  him  as  being  of  weak 
mind  and  likel/  to  be  easily  affected  by  drink,  but  he  could  not 
certify  him  as  insane.  The  charge  was  reduced  to  one  of  common 
assault,  and  the  magistrate  thought  it  would  be  good  for  the 
youth  to  go  to  prison,  and  committed  him  for  two  months." 

"G.  E.  R.,  aged  nineteen,  was  indicted  for  endangering  the 
safety  of  persons  being  conveyed  upon  the  London  and  North- 
western Railway  by  placing  a  coil  of  disused  electric  wire  on  the 
line  in  such  a  position  as  to  be  in  the  way  of  any  passing  trains. 


304  Mental  Deficiency 

Prisoner  was  a  typewriter  and  shorthand  clerk,  and  no  motive 
could  be  assigned  for  his  act.  He  was  admittedly  weak-minded, 
but  beyond  that  the  medical  officers  who  had  had  him  under 
observation  could  not  go.  He  was  convicted  of  misdemeanour 
only,  and  sentenced  to  pay  a  fine  of  ;f5o,  or  in  default  to  undergo 
six  months'  imprisonment  ;  also  to  find  two  sureties  in  £$0 
each  to  keep  the  peace  for  twelve  months,  or  go  to  prison  for 
six  months  in  default." 

"  T.  P. — Owing  to  the  extraordinary  series  of  grave  outrages 
committed  in  Nottinghamshire  and  the  immediate  district  during 
the  past  month,  much  importance  was  attached  to  a  case  which 
occupied  the  attention  of  the  Mansfield  Bench.  The  man  in 
custody,  a  labourer  named  T.  P.,  aged  twenty-three,  a  deaf-mute 
of  weak  intellect,  was  charged  with  feloniously  placing  a  wooden 
gate  on  the  Great  Central  line  at  Kirkby-in-Ashfield.  P.  has 
been  in  the  habit  of  sleeping  out,  although  his  reputed  place  of 
abode  is  at  Sutton-in- Ashfield,  within  which  area  there  have  been 
a  number  of  abortive  attempts  at  train- wrecking.  In  addition, 
the  neighbouring  parish  churches  of  Kirkby  and  Annesley  have 
been  destroyed  by  fire  upon  successive  nights,  both  disasters 
being  the  work  of  an  incendiary.  Prisoner  was  apprehended  in 
a  shed  at  some  brickworks.  He  showed  the  police-officers  a 
spot  on  the  railway  where  he  said  he  placed  a  wooden  gate  on 
the  rails.  Dr.  Gray,  who  had  examined  prisoner,  gave  evidence 
that  P.  was  a  lunatic  and  a  proper  person  to  be  taken  charge  of. 
Deputy-Chief-Constable  Harrop  said,  as  accused  was  certified 
insane,  no  evidence  would  be  offered.  The  man  was  first  arrested 
in  connexion  with  a  robbery  at  Ulfreton  Railway-station,  and 
the  proceeds  were  found  in  his  possession  ;  other  robberies  on 
the  railway  had  been  also  traced  to  him.  Prisoner  took  witness 
and  Police-Constable  Fryer  to  Suiton-in-Ashfield,  and  across 
some  fields  to  the  Great  Central  Railway  at  Kirkby,  where  he 
pointed  out  the  exact  spot  at  which  an  obstruction  had  been 
placed  on  the  line.  He  exhibited  great  satisfaction  when  a 
train  approached,  and  showed  where  he  had  obtained  the  gate 
and  had  hidden  himself  until  a  train  dashed  into  the  obstruction. 
Afterwards  prisoner  showed  exactly  where  two  pairs  of  trolly 
wheels  and  a  wheelbarrow  attached  had  been  placed  on  the  line. 
Accused  was  ordered  to  be  sent  to  a  lunatic  asylum." 


Moral   Deficiency  and  Criminal  Aments        305 


Criminal  Responsibility  of  Aments. 

The  law  of  England  recognizes  that  persons  suffering  from 
certain  forms  of  mental  disease  cannot  be  held  accountable  for 
their  actions,  and,  generally  speaking,  this  is  the  case  with 
idiots  and  pronounced  imbeciles,  or  any  person  who,  in  the  words 
of  Mr.  Justice  Tracey  (1723),  knows  what  he  is  doing  "  no  more 
than  an  infant,  a  brute,  or  a  wild  beast."  With  regard  to  the 
milder  degrees  of  defect,  however,  the  mere  presence  of  feeble- 
mindedness does  not  of  necessity  absolve  a  person  from  the 
consequences  of  his  acts,  and  the  criminal  responsibility  of  such 
persons,  as  well  as  of  the  insane,  is  by  no  means  clearly  defined. 
There  are  certain  precedents  and  rulings  which  are  usually 
followed  in  such  cases,  but  in  any  particular  instance  the  fact 
of  the  responsibility  or  otherwise  of  the  accused  is  a  question 
for  the  jury  to  decide  upon  the  evidence  presented  to  them. 
Criminal  offences  in  which  this  question  of  responsibility  is 
raised  are  exceedingly  common,  and  it  is  plainly  the  duty  of 
the  members  of  our  profession,  who  alone  can  form  a  correct 
estimate  as  to  the  extent  to  which  conduct  is  likely  to  be 
influenced  by  mental  deficiency  or  disease,  to  formulate  general 
principles,  and  to  give  their  opinion  regarding  the  mental  con- 
dition of  any  particular  accused  person  in  order  that  the  jury 
may  arrive  at  this  decision.  These  general  principles,  however, 
must  be  just,  and  whilst  protecting  those  who  are  really  ir- 
responsible from  undeserved  punishment,  they  must  also  protect 
society  against  the  escape  from  punishment  of  those  who,  even 
if  mentally  deficient,  are  rightly  accountable  for  their  actions. 

The  rulings  of  English  Courts  at  the  present  time  are  generally 
based  upon  the  replies  of  the  fifteen  Judges  to  the  House  of  Lords 
in  the  middle  o^  the  last  century.  Briefly,  it  may  be  stated  that 
for  an  accused  person  to  be  held  irresponsible  on  the  ground  of 
insanity,  it  must  be  shown  that  he  was  of  diseased  mind,  and 
that  at  the  time  he  committed  the  act  he  was  not  conscious  of 
right  or  wrong,  or  was  under  some  delusion  which  made  him 
regard  the  act  as  right. 

This  dictum,  it  will  be  observed,  takes  no  account  of  the 
question  of  defective  control,  an  omission  which  was  pointed  out 

20 


3o6  Mental  Deficiency 

in  the  exhaustive  treatise  of  Sir  Fitzjames  Stephen.  According 
to  this  eminent  jurist,  "  No  act  is  a  crime  if  the  person  who  does 
it  is,  at  the  time  when  it  is  done,  prevented  from  controlling  his 
own  conduct,  unless  the  absence  of  the  power  of  control  has  been 
produced  by  his  own  default."  I  do  not  propose  to  enter  into 
any  discussion  regarding  the  diminution  of  the  will  in  ordinary 
persons  or  even  in  insanity  ;  but  I  am  quite  certain  that  in  persons 
suffering  from  amentia  a  diminished  power  of  control  is  so  com- 
monly present,  and  such  an  essential  part  of  their  mental  con- 
dition, that  a  grave  injustice  may  be  done  if  this  be  not  taken 
into  account.  There  may  be  non-defective  persons  who,  whilst 
fully  appreciating  the  nature  and  consequences  of  certain  criminal 
acts,  are  yet  incapable  of  refraining  from  committing  them,  and 
such  cases  are  described  as  impulsive  insanity.  But  it  cannot 
be  doubted  that  there  are  aments  who  suffer  from  a  definite 
defect  of  control  which  leads  them  to  commit  criminal  acts.  I 
would  therefore  say  that,  whilst  the  mentally  deficient  person 
is  hot  necessarily  irresponsible  for  any  crime  he  may  commit, 
he  should  certainly  be  held  unaccountable  when  he  commits  an 
act  (i)  of  which  he  does  not  understand  the  nature  or  that  it 
is  contrary  to  law  ;  (2)  which  is  the  result  of  an  impulse  he  was 
unable  to  control ;  (3)  which  is  the  natural  result  of  a  delusion  of 
which  he  is  shown  to  be  the  subject. 

With  regard  to  these  particular  qualifying  conditions  a  few 
words  may  be  said,  (i)  Want  of  knowledge  as  to  the  nature 
or  illegality  of  the  act  would  usually  be  capable  of  ready  demon- 
stration in  the  case  of  idiots  and  imbeciles  ;  but  even  in  the 
milder  grades  defective  intelligence  or  education  might  still 
result  in  ignorance  as  to  how  wrong  the  act  was  or  that  it  was 
forbidden  by  law.  As  was  ably  pointed  out  by  Sir  Fitzjames 
Stephen  :  "  Knowledge  has  its  degrees  like  everything  else, 
and  implies  something  more  real  and  more  closely  connected 
with  conduct  than  the  half  knowledge  retained  in  dreams."  As 
an  instance  this  author  quotes  the  extreme  case  of  the  idiot  who 
cut  off  the  head  of  a  man  whom  he  found  asleep,  remarking  that 
it  would  be  great  fun  to  see  him  look  for  it  when  he  woke  ;.  and 
he  adds  :  "  Nothing  is  more  probable  than  that  the  idiot  would 
know  that  people  in  authority  would  not  approve  of  this,  that 
it  was  wrong  in  the  sense  in  which  it  is  wrong  in  a  child  not  to 


Moral   Deficiency  and  Criminal   Aments        307 

learn  its  lesson,  and  he  obviously  knew  that  it  was  a  mischievous 
trick."  And  it  cannot  be  doubted  that  the  same  kind  of  in- 
complete knowledge  as  to  how  wrong  an  act  is  exists  in  the  case 
of  many  persons  suffering  from  a  mild  degree  of  mental  deficiency. 
The  high  grade  ament  at  Earlswood  asylum,  who  has  been  men- 
tioned as  attempting  the  destruction  of  an  official  who  had 
displeased  him,  undoubtedly  knew  that  in  so  doing  he  was  doing 
what  was  wrong,  but  I  do  not  for  one  moment  think  that  he 
appreciated  how  wrong  his  act  was,  or  that,  had  it  succeeded, 
he  could  justly  have  been  held  fully  accountable  for  it.  Dr. 
Mercier,*  commenting  on  this  question  in  his  recent  philosophical 
treatise,  says  :  "  It  is  a  truth  on  which  I  have  insisted  in  season 
and  out  of  season  for  many  years,  that  a  man  may  know  that 
his  act  is  wrong  without  knowing  how  wrong  it  is." 

(2)  Pronounced  defect  of  control  in  aments  is  usually  clearly 
evident  from  infancy,  although  in  some  cases  it  may  not  attract 
attention  until  puberty.  It  is  one  of  the  chief  characteristics 
of  the  "  facile  "  and  **  impulsive  "  types  of  amentia,  and  of  some 
of  the  epileptics.  It  is  also  a  prominent  feature  in  many  of  those 
persons  we  have  described  as  "  moral  defectives  "  or  habitual 
criminals,  who  repeatedly  (and  often  openly)  commit  offences 
absolutely  undeterred  by  punishment.  As  an  extreme  instance 
of  this  the  case  related  by  Dr.  Gray,  lately  physician  to  the 
Ameer  of  Afghanistan  (mentioned  in  Dr.  Mercier's  book),  is 
worthy  of  note.  It  is  that  of  a  man  "  who,  after  having  had 
first  his  right  hand,  and  subsequently  his  left  hand,  struck  off 
as  a  punishment  for  theft,  seized  with  his  stumps  and  made  off 
with  an  earthenware  pot  of  trifling  value,  and  of  no  use  whatever 
to  him.  The  crime  was  witnessed  and  the  criminal  at  once 
arrested  and  taken  before  the  Ameer,  who  sentenced  him,  as 
he  must  have  expected,  to  be  hanged  ;  and  hanged  he  accord- 
ingly was."  Dr.  Mercier  also  mentions  the  case  of  a  cadet  at 
Sandhurst,  who  stole  the  boots  and  clothes  of  a  comrade,  although 
he  was  amply  supplied  by  his  father,  and  had  no  need  of  the 
things  stolen.  He  stole  them  without  any  concealment,  and 
actually  wore  them  in  the  presence  of  their  owner.  He  was 
expelled,  and  on  his  return  home,  although  standing  in  awe  and 
terror  of  his  father,  nevertheless  cleared  the  latter's  dressing- 

*  Charles  Mercier,  "  Criminal  Responsibility, "  1905. 

20 — 2 


3o8  Mental  Deficiency- 

table  of  its  ivory  brushes  and  silver  furniture,  and  sold  them  to 
a  passer-by  for  five  shilHngs. 

Quite  recently  I  was  consulted  with  regard  to  an  almost 
precisely  similar  case  in  the  shape  of  a  youth  at  a  public  school 
who,  although  liberally  supplied  from  home,  and  having  every- 
thing he  needed,  systematically  purloined  his  companions' 
property  of  every  description.  This  youth  was  by  no  means  un- 
intelligent, in  fact,  in  several  subjects  he  occupied  a  high  place 
in  his  form,  and  his  general  appearance  and  conversation  were 
so  prepossessing  that  anyone  not  acquainted  with  the  type  would 
almost  certainly  feel  that  some  horrible  mistake  had  been  made. 
His  only  observable  peculiarities  consisted  of  a  somewhat  wander- 
ing attention,  a  general  restlessness,  and  several  little  tricks 
such  as  constantly  putting  his  hand  to  his  collar,  etc.  And  yet, 
when  I  questioned  him  about  his  misdeeds,  he  acknowledged 
them  without  any  shame  or  concealment,  and  I  found  that  he 
had  been  expelled  from  two  other  schools  for  similar  practices. 
I  am  inclined  to  think  that  in  some  of  the  milder  cases  of  this 
kind  recovery  may  take  place  under  suitable  treatment  and 
some  degree  of  moral  sense  be  developed  ;  but  pronounced  cases 
like  these  described  are  practically  hopeless,  and  although  it 
may  be  extremely  difficult  in  some  of  them  to  detect  any  intel- 
lectual deficiency,  and  to  differentiate  badness  from  madness, 
the  fact  of  such  senseless  depredations  in  spite  of  punishment 
would  of  itself  lead  one  to  infer  that  an  intellectual  defect  did, 
in  reality,  exist.  On  the  other  hand,  there  can  be  no  doubt  that 
"  moral  deficiency,"  or  as  it  is  sometimes  more  euphemistically 
described  *'  kleptomania,"  is  often  put  forward  as  a  defence  when 
the  individual  is  fully  accountable  for  his  actions.  Personally  I 
should  be  very  loth  to  admit  defective  will-power  as  an  excuse 
for  a  criminal  offence  unless  the  accused  were  of  one  of  the  types 
which  have  been  described,  or  there  were  evidence  of  the  previous 
commission  of  impulsive  acts. 

(3)  The  commission  of  criminal  acts  in  consequence  of  delusions 
practically  only  occurs  in  the  case  of  aments  who  are  also  insane. 
These  will  be  described  in  the  following  chapter,  but  here  it  may 
be  stated  that,  although  the  combination  of  insanity  and  mental 
deficiency  would  raise  a  strong  presumption  as  to  the  irresponsi- 
bility of  the  individual  so  affected,  he  could  only  justly  and 


Moral  Deficiency  and  Criminal  Aments       309 

logically  be  held  unaccountable  for  the  commission  of  a  criminal 
act  when  it  was  clearly  shown  that  his  mental  disease  did,  in 
fact,  prevent  him  from  knowing  the  nature  and  quality  of  the 
act  at  the  time  it  was  done,  or  from  knowing  that  the  act  was 
wrong,  or  from  controlling  his  own  conduct.  For  as  Mr.  Justice 
Stephen  said  :  "  An  act  may  be  a  crime  although  the  mind  of 
the  person  who  does  it  is  affected  by  disease,  if  such  disease  does 
not,  in  fact,  produce  upon  his  mind  one  or  other  of  the  effects 
above  mentioned  in  reference  to  that  act." 

It  is  thus  seen  that,  although  an  inquiry  into  the  criminal 
responsibihty  of  a  person  must,  of  necessity,  take  into  account 
the  state  of  that  person's  mind,  yet  the  question  is  not  in  reahty 
a  medical,  but  a  legal  one.  It  is  the  duty  of  the  physician  to 
place  before  the  court  full  and  impartial  evidence  regarding  the 
presence  or  absence  of  such  mental  disease,  disorder,  or  deficiency 
as  would  influence  conduct  ;  but  it  is  the  duty  of  the  judge  and 
jury  to  decide  whether  this  defect  or  disease  has  so  influenced 
conduct  as  to  render  the  a>ccused  partially  or  wholly  irresponsible 
for  his  act. 

In  defining  the  **  conditions  of  responsibility,"  Dr.  Mercier 
arrives  at  the  conclusion  that  **to  incur  responsibility  by  a  harm- 
ful act,  the  actor  must  will  the  act  ;  intend  the  harm  ;  desire 
primarily  his  own  gratification.  Furthermore  the  act  must  be 
unprovoked,  and  the  actor  must  know  and  appreciate  the  circum- 
stances in  which  the  act  is  done." 

With  regard  to  civil  incapacity,  an  idiot  has  no  civil  rights, 
but  a  person  suffering  from  feeble-mindedness  could  only  be 
adjudged  incapable  of  managing  his  affairs  by  proceedings 
in  Chancery.  In  such  a  case  trustees  of  the  estate  might  be 
appointed  without  depriving  the  person  of  his  liberty  ;  in  other 
words,  he  might  be  declared  incapable  of  managing  his  affairs, 
but  capable  of  managing  himself. 

An  idiot  is  inadmissible  as  a  witness,  but  in  the  case  of  an 
imbecile  or  feeble-minded  person  it  is  for  the  Judge  to  examine 
and  ascertain  whether  he  is  of  competent  understanding  to  give 
evidence,  and  is  aware  of  the  nature  and  obligation  of  an  oath  ; 
if  satisfied  that  he  is,  the  Judge  wiU  probably  allow  him  to  be 
sworn  and  examined. 


CHAPTER   XVII 

INSANE  AMENTS 

In  the  literal  sense  of  the  word  "  insanity,"  all  aments  may  be 
looked  upon,  and  are  often  described,  as  "  congenitally  insane." 
But  nowadays  there  is  a  tendency  to  restrict  the  term  to  those 
cases  in  which  there  is  a  perversion  of  the  ego,  and  it  is  in  this 
sense  that  it  is  here  used.  Dr.  Savage  says  a  man  must  be 
considered  as  sane  or  insane  in  relation  to  himself,  and  although 
such  a  definition  would  render  "  congenital  "  insanity  an  im- 
possibility, the  variations  of  mental  function  and  capacity  in 
the  mentally  deficient  are  so  great  that,  from  the  standpoint 
of  amentia,  there  is  much  to  be  said  in  favour  of  using  the  ego 
rather  than  the  "normal"  or  "mean  average"  as  a  standard 
of  reference. 

A  large  number  of  aments  react  to  their  environment  in  a 
perfectly  consistent,  uniform,  and,  as  far  as  their  mental  capacity 
will  admit,  normal  manner,  and  such  may  be  considered  sane, 
albeit  defective.  On  the  other  hand,  a  certain  number  are 
characterized  by  lapses  from  their  ordinary  mental  state  of  such 
intensity  that,  for  the  time  being,  they  may  rightly  be  termed 
insane  ;  it  is  with  these  latter  that  this  chapter  deals. 

The  causes  which  actually  determine  insanity  are  many  and  • 
varied,  ranging  from  a  slight  alteration  of  the  general  bodily 
health  and  condition  to  a  sudden  strain  or  prolonged  mental  or 
nervous  stress.     As  Mercier  says,  however,  "  a  jerry-built  villa 
is  liable  to  be  blown  down  by  a  storm  of  wind,  but  nothing  short 
of  an  earthquake  will  destroy  a  well-constructed  mansion."     Andj 
in  the  great  majority  of  cases  of  insanity  there  is  a  predisposingX 
cause — namely,  an  instability  of  nervous  tissue.     This  instabilityj 
may  be  congenital  or  acquired,  generally  the  former,  and,  iil 

310 


Insane  Aments  3  1 1 

view  of  the  defective  structure  which  is  the  essential  basis  of 
amentia,  it  is  not  surprising  that  in  many  of  these  persons  there 
should  be  a  decided  nervous  instability  and  consequent  proneness 
to  insanity  ;  this  is  found  to  be  the  case. 

It  is  probable  that  the  actual  number  of  aments  who  are  thus 
predisposed  to  insanity  is  incapable  of  determination,  just  as  it 
is  impossible  to  calculate  the  proportion  of  potential  lunatics  in 
the  non-defective  population  ;  but  an  appro xim^-te  estimate  of 
the  number  of  the  feeble-minded  grade  of  aments  who  are  actually 
insane  can  be  made,  and  a  comparison  of  this  with  the  number 
of  the  ordinary  insane  will  give  an  idea  of  the  relative  predisposi- 
tion in  the  two  classes. 

From  information  which  has  been  very  courteously  placed  at 
my  disposal  by  some  asylum  physicians,  as  well  as  from  my  own 
observations  in  the  asylums  of  the  London  County  Council  and 
elsewhere,  I  am  of  opinion  that  at  least  5  percent,  of  the  inmates 
of  the  county  and  borough  asylums  of  this  country  are  feeble- 
minded  insane ;  we  may  therefore  estimate  the  number  of 
feeble-minded  certified  lunatics  as  approximately  4,450,  or  about 
8  percent,  of  the  total  feeble-minded  of  the  country  (54,114). 

The  proportion  of  ordinary  or  non-defective  insane  to  the 
total  population  is  only  about  0*3  per  cent.,  from  which  it  appears 
that  the  predisposition  to  insanity  in  the  feeble-minded  is  twenty- 
six  times  that  of  the  ordinary  population.  There  are,  of  course, 
many  of  the  non-defective  insane  who  are  not  certified,  but  so 
there  are  of  the  mentally  deficient  insane,  and  I  think  that  these 
figures  express  the  relative  predisposition  to  insanity  which  exists 
in  the  two  classes  with  tolerable  accuracy.  On  the  whole  I  think 
we  may  say  that  close  on  10  per  cent,  of  the  feeble-minded  have 
a  definite  insane  predisposition.  With  regard  to  this  tendency 
in  imbeciles  and  idiots,  I  am  unable  to  give  any  figures,  but  my 
impression  is  that,  although  it  is  considerably  less  than  in  the 
merely  feeble-minded,  it  is  still  much  greater  than  in  the  ordinary 
population. 

There  is  no  doubt  that  a  considerable  number  of  the  non- 
defective  insane  manifest  signs  of  a  diminished  power  of  will  or 
inhibition  from  a  very  early  age,  and  some  writers  would  go  so 
far  as  to  include  these  with  the  aments  proper.*     It  cannot  be 

*  See  Bolton,  "  Amentia  and  Dementia,"  Journal  of  Mental  Science,  1907. 


312  Mental  Deficiency 

denied  that  there  is  much  to  be  said  for  such  a  view,  for  these 
persons  often  present  a  physiognomy,  and  also  stigmata  of 
degeneracy,  identical  with  those  existing  in  the  mentally  defec- 
tive. I  doubt,  however,  whether  these  should  really  be  classed 
as  aments,  although  they  are  undoubtedly  on  the  borderland 
between  this  condition  and  insanity,  between  a  brain  which  is 
the  seat  of  an  actual  arrest  of  anatomical  structure  and  one 
which  is  merely  unstable  and  of  defective  physiological  poten- 
tiality. They  serve  to  show  that,  just  as  the  three  grades  of 
amentia  merge  into  one  another,  so  in  turn  do  the  mildest 
members  of  the  aments  stand  in  an  extremely  close  relationship 
to  the  insane — that  idiocy  is,  indeed,  the  culmination  of  the 
neuropathic  diathesis.  In  this  place,  however,  I  shall  use  the 
term  "  amentia  "  in  the  manner  in  which  it  has  all  along  been 
used,  and  shall  only  refer  to  those  persons  who  show  definite 
intellectual  deficiency. 

In  a  certain  number  of  these  aments  who  become  insane  there 
are  determining  factors,  just  as  in  the  ordinary  lunatics  ;  but,  on 
the  whole,  these  factors  are  much  less  in  evidence,  and  as  we 
proceed  down  the  scale  of  mental  deficiency  they  become  still 
less  and  less  frequent.  In  the  imbeciles  an  attack  of  insanity 
may  suddenly  appear  without  any  apparent  determining  cause 
whatever,  and  the  sudden  and  violent  storms  of  the  idiot,  which 
must  be  looked  upon  as  of  precisely  the  same  nature  as  true 
insanity,  are  similarly  unrelated  to  any  obvious  cause.  The 
extreme  mental  instability  present  in  these  persons  must  be 
considered  as  of  itself  sufficient  to  determine  the  attack :  the 
"  jerry-built  villa  "  topples  over,  not  by  reason  of  any  storm  of 
wind,  but  because  of  its  own  unstable  equilibrium. 

This  instability,  as  I  have  already  remarked,  is  usually  present 
and  recognizable  from  childhood.  As  a  boy  or  girl  the  patient 
has  been  subject  to  fits  of  irritability,  moroseness,  or  bad  temper, 
often  accompanied  by  acts  of  violence,  which  have  been  a  cause 
not  only  of  sorrow,  but  of  anxiety,  to  friends  and  relations ;  and 
although  these  conditions  can  hardly  be  termed  insanity,  they  are 
the  shadows  of  the  coming  event,  being  evidence  of  that  special 
predisposition  which  wiU  almost  inevitably,  sooner  or  later, 
terminate  in  insanity.  It  is  possible  that,  could  the  youth  and 
adolescence  of  a  feeble-minded  person  of  this  class  be  passed 


Plate  XXVII. 


To  /(ice  page  312.] 


Insane   Aments  313 

in  a  perfectly  orderly  and  routine  manner,  away  from  the  bustle 
of  the  outside  world,  the  attack  might  be  long  deferred,  or  even 
prevented.  In  the  majority  of  cases,  however,  the  first  attack 
makes  its  appearance  between  the  periods  of  puberty  and 
adolescence,  and  in  some  cases  even  much  earlier  than  this. 

One  of  the  most  frequent  exciting  causes  in  the  mild  aments 
is  alcohol,  to  the  action  of  which  the  mentally  defective,  and, 
indeed,  neuropaths  generally,  seem  to  be  peculiarly  susceptible 
and  particularly  intolerant.  A  severe  fright  may  likewise  pre- 
cipitate an  attack  of  insanity  in  one  of  these  persons.  I  remember 
a  mentally  defective  child  who,  for  some  breach  of  school  disci- 
pHne,  was  shut  up  by  the  teacher  in  a  small  dark  room,  little 
better  than  a  cupboard.  When  taken  out  he  was  silent,  and 
apparently  dazed.  The  teacher  said  he  was  sulky,  but  he  con- 
tinued moody  and  depressed,  and  a  few  days  afterwards  passed 
into  a  state  of  profound  melancholia  which  necessitated  his 
removal  to  an  asylum.  Religious  or  other  forms  of  excitement 
may  also  act  as  determining  causes.  One  small  boy  of  twelve 
years  became  acutely  maniacal  as  a  result  of  the  popular  excite- 
ment attending  the  relief  of  Mafeking.  Another  mentally  de- 
fective youth  in  the  employ  of  an  Evangelical  clergyman  was  so 
worried  by  this  zealous  but  indiscriminate  gentleman  about  his 
soul  that  he  attempted  suicide.  Another  feeble-minded  young 
man  became  insane  in  consequence  of  the  repeated  theatre- 
going  and  sight-seeing  provided  by  his  relations  with  the  idea  of 
amusing  him.  In  fact,  almost  any  trifling  occurrence,  which 
would  have  no  effect  upon  the  mind  of  a  healthy  person,  seems 
to  be  enough  to  upset  the  equilibrium  of  these  mentally  unstable 
defectives,  and  often  the  mere  physiological  changes  consequent 
upon  puberty  or  adolescence  are  sufficient. 

I  have  already  remarked  that  insanity  is  commoner  in  the 
milder  than  in  the  more  severe  grades  of  amentia,  and  in  the 
latter  it  also  tends  to  be  of  a  somewhat  different  type  to  that 
in  the  feeble-minded.  The  insanity  of  the  feeble-minded 
and  high-grade  imbeciles  does  not,  on  the  whole,  differ  from 
that  occurring  in  ordinary  persons,  and  to  give  some  idea  of  the 
relative  frequency  of  the  different  clinical  types,  I  may  state 
that,  in  62  of  these  cases  which  I  had  under  my  observation 
for  a  considerable  period,  mania  was  present  in  32,  melancholia 


3H  Mental  Deficiency 

in  i6,  alternating  mania  and  melancholia  in  6,  stupor  in  i,  delu- 
sional insanity  in  i,  and  juvenile  general  paralysis  in  6.  I  doubt 
whether  the  relative  incidence  of  juvenile  general  paralysis  is 
really  so  great  as  would  appear  from  these  figures,  in  consequence 
of  the  fact  that  the  helpless  demented  condition  of  these  persons 
leads  to  the  committal  of  an  undue  proportion  of  them  to  asylum 
care. 

It  will  be  of  interest  to  give  some  particulars  regarding  the 
patients  suffering  from  these  different  forms  of  insanity. 

Mania. — Fourteen  of  the  patients  suffering  from  mania  were 
males,  and  eighteen  females.  In  about  two-thirds  of  the  cases 
definite  delusions  were. present,  chiefly  relating  to  the  identity 
of  the  patients  or  those  about  them.  In  twelve  of  the  cases  there 
were  well-marked  aural  or  visual  hallucinations.  All  these 
attacks  presented  the  usual  characteristics  of  acute  mania,  the 
patients  gesticulating,  shouting,  singing,  and  rushing  about,  for 
days  together  without  cessation.  Sometimes  they  were  exceed- 
ingly violent,  using  abominable  language,  and  smashing  every- 
thing within  reach,  so  that  confinement  to  the  padded  room  was 
necessary.  One  girl  of  fourteen  years  attacked  her  brothers 
and  sister  with  a  poker  and  table-knives ;  whilst  another,  aged 
sixteen,  stabbed  her  grandmother  and  attempted  to  set  fire  to 
the  house.  One  of  these  patients,  who  was  recovering,  accounted 
for  his  actions  by  saying  that  he  "  got  some  thought  on  his 
mind,  which  he  tried  to  get  off  and  couldn't  ;  this  caused  the  blood 
to  rush  to  his  head,  and  sent  it  rushing  down  his  arms  and  legs." 
I  am  of  opinion  that  a  considerable  proportion  of  feeble-minded 
criminals  are  of  this  type,  and  that  their  offences  are  often  com- 
mitted whilst  they  are  actually  insane. 

Melancholia. — Of  the  sixteen  cases  of  melancholia,  seven 
were  males,  and  nine  females.  Definite  delusions  or  hallucina- 
tions were  ascertained  to  be  present  in  three-quarters  of  the 
cases.  In  eleven  patients  suicide  was  threatened  or  attempted, 
and  in  seven  there  was  refusal  of  food.  Both  active  and 
passive  varieties  of  melancholia  occurred,  the  former  being  a 
trifle  more  frequent.  The  active  form  was  commonly  preceded 
or  accompanied  by  terrifying  delusions  or  hallucinations.  Thus, 
one  young  girl  was  frightened  by  seeing  a  fight  in  the  street ; 
she  became  timid  and  anxious,  and  in  a  few  days  developed  pro- 


h 


M 


Plate  XXVIII. 


To /(ice  page  314] 


Insane  Aments 


315 


nounced  delusions  to  the  effect  that  people  were  trying  to  kill 
and  burn  her.  She  heard  voices  threatening  her,  thought  that  her 
food  was  poisoned,  and  refused  to  eat  it,  and,  in  fact,  became 
apprehensive  of  harm  from  every  imaginable  quarter.  She  was 
in  a  restless  state  of  tearful  agitation,  constantly  wringing  her 
hands,  and  muttering,  "  What  are  they  going  to  do  to  me  ?" 
Another  boy  had  the  curious  delusion  that  he  had  fallen  to  pieces 
and  lost  some  of  his  parts.  The  passive  form  of  melancholia  of 
these  persons  seems  at  times  to  be  the  outcome  of  a  morbid 
consciousness  that  they  are  not  quite  as  other  people.  They  feel 
neglected,  or,  as  they  sometimes  say,  "  of  no  use."  The  rebuke  or 
sharp  word  of  employer  or  parent  is  keenly  felt,  and  they  acquire 
a  habit  of  brooding  over  their  fancied  wrongs.  It  is  very  common 
to  hear  feeble-minded  persons  in  this  frame  of  mind  complain 
that  they  have  "  not  had  fair  play."  Pronounced  delusions  of 
persecution  soon  follow,  and  these  pass  into  a  state  of  apathetic 
melancholia.  If  they  can  be  got  to  converse  at  all,  their  remarks 
will  often  be  to  the  effect  that  they  are  "  tired  of  life  and  want  to 
die,"  and,  indeed,  attempts  at  suicide  are  by  no  means  un- 
common. These  attempts  are  often  real  and  definite  efforts 
to  put  an  end  to  existence,  and  drowning  seems  to  be  the  method 
which  most  appeals  to  them.  Many  of  these  patients  become 
utterly  careless  of  personal  cleanhness,  refuse  to  work,  dress,  or 
take  food,  and  sometimes  resist  any  attempt  on  the  part  of  their 
attendants  to  see  to  these  matters  for  them. 

Stupor. — ^This,  apparently,  is  not  very  common  in  the  feeble- 
minded, but  I  have  seen  one  well-marked  case  which,  beginning 
as  passive  melancholia,  with  visual  hallucinations  and  refusal 
of  food,  gradually  developed  into  a  condition  of  complete  stupor 
— indeed,  almost  catalepsy.  The  patient  was  a  mentally  defec- 
tive boy  of  fifteen  years,  and  for  weeks  he  sat  in  one  place,  staring 
vacantly  in  front  of  him,  dribbling  from  his  mouth,  requiring  to 
be  fed  with  a  spoon,  and  absolutely  indifferent  to  the  calls  of 
nature.  He  was  discharged  cured  from  the  asylum  in  nine 
months,  but  readmitted  six  months  later  with  a  precisely  similar 
attack.  This  in  turn  slowly  passed  away  after  a  few  months, 
to  be  followed  by  a  state  of  extreme  fatuity,  the  youth  being 
liable  to  sudden  outbursts  of  laughter  or  crying  without  any 
observable  cause  (see  Fig.  67). 


3i6  Mental  Deficiency 

Alternating  Insanity. — In  six  of  the  cases  the  insanity  took 
the  form  of  alternating  attacks  of  mania  and  melancholia.  In 
these  patients,  however,  there  were  no  intervening  periods  of 
complete  cessation,  as  in  the  folie  circniaire  of  French  authors. 
The  mania,  which  was  violent  and  acut^,  lasted  for  a  time,  and 
was  then  replaced  by  a  state  of  melancholia  of  the  ordinary 
variety,  or  vice  versa,  and  so  the  process  continued.  Perhaps 
they  should  rather  be  classed  as  recurrent  insanity.  Two  of  them 
have  now  definite  indications  of  approaching  dementia. 

Delusional  Insanity. — I  do  not  think  that  a  pure  delusional 
insanity  is  common  in  aments,  but  one  case  seems  to  be  best 
placed  in  this  category.  It  is  that  of  a  feeble-minded  youth, 
aged  twenty-three  years,  who  since  the  age  of  nineteen  has  re- 
mained in  the  same  condition.  There  is  neither  excitement  nor 
depression  ;  and  he  is  quite  happy  and  good-natured,  telling 
every  one  that  he  owns  a  lot  of  money  in  the  bank,  that  he 
teaches  music  at  sixpence  a  lesson,  and  that  he  performs  on  the 
Aquarium  stage.  Not  infrequently  feeble-minded  children  and 
adults  will,  under  the  influence  of  delusions  or  hallucinations, 
make  unfounded  charges  against  their  companions  or  teachers, 
and  sometimes  they  will  do  the  same  from  pure  wickedness.  It 
is  very  necessary  to  bear  this  fact  in  mind  in  any  investigation, 
for  the  statements  are  often  so  circumstantial  as  to  excite  a 
ready  credence  in  the  unguarded. 

Recurrences. — In  about  one-third  of  these  cases  there  was  no 
recovery  from  the  first  attack  ;  the  mania  or  melancholia  became 
lessened  in  its  intensity,  but  persisted  as  chronic  insanity,  to 
gradually  terminate  in  dementia.  In  about  two-thirds  of  the 
cases,  however,  the  first  attack  gradually  and  completely  sub- 
sided after  a  period  varying  from  a  few  weeks  to  two  or  three 
months  ;  but  the  improvement  was  only  temporary,  and,  as  far 
as  my  experience  goes,  there  is  scarcely  any  class  of  patient 
in  whom  a  recurrence  is  more  likely  to  take  place.  This  is 
seldom  deferred  for  more  than  a  year,  and  in  the  majority  of 
the  cases  it  comes  on  within  a  few  months  of  the  subsidence  of 
the  original  attack.  The  second  and  subsequent  attacks  are 
usually  of  the  same  clinical  type  as  the  first,  and  they  continue 
to  occur  at  periods  varying  from  three  to  twelve  months  for 
many  years.     In  the  intervals  the  patient  is  fairly  quiet,  and 


Plate  XXIX. 


To /ace  page  316.] 


Insane  Aments 


317 


may  do  a  certain  amount  of  useful  work,  although  his  mental 
deficiency  and  instability  prevent  any  regular  employment. 
With  the  lapse  of  time,  however,  the  insane  attacks  tend  to  recur 
more  and  more  frequently,  and  the  patient  gradually  passes 
into  a  state  of  chronic  insanity,  which  is  only  terminated  by  the 
development  of  dementia. 

Dementia. — Many  aments  become  demented  in  their  later 
years,  and  secondary  dementia  is  the  natural  termination  of  most 
of  these  cases  of  insanity,  its  advent  depending  chiefly  upon  the 
type  and  the  frequency  with  which  recurrences  occur.  On  the 
other  hand,  primary  dementia  in  young  aments  is  of  such  rare 
occurrence  that  its  presence,  without  antecedent  insanity  or 
epilepsy,  is  nearly^ always  indicative  of  juvenile  general  paralysis. 
In  the  insanity  accompanying  epilepsy,  or  even  in  severe 
epilepsy  without  insanity  in  these  patients,  dementia  is  usually 
ushered  in  fairly  early.  In  the  sudden  and  violent  storms  of 
the  emotional  type,  on  the  other  hand,  it  is  late,  and  I  have 
known  such  patients  show  no  sign  of  dementia  after  many  years. 
The  ordinary  attacks  of  insanity  seem  to  lie  midway  between 
these  two  extremes,  and  in  most  of  my  cases  definite  symptoms 
of  dementia  were  observable  within  about  eight  years  of  the 
first  attack. 

It  is  thus  seen  that  in  the  life  cycle  of  the  ament  we  may  have 
an  epitome  of  all  the  main  varieties  of  mental  disease.  Beginning 
with  a  defective  brain,  he  may  early  show  signs  of  mental  insta- 
bility and  imperfect  function ;  this  passes  on  into  various  types 
of  insanity,  and  fiinally  culminates  in  complete  degeneration  of  all 
the  little  faculty  he  once  possessed — dementia. 

General  Paralysis. — My  figures  are  not  sufficiently  numerous 
to  enable  me  to  state  definitely  to  what  extent  this  occurs,  but 
amongst  rather  more  than  200  aments  in  the  asylums  of  the 
London  County  Council  I  met  with  six  instances  (three  males 
and  three  females).  The  disease  may  be  of  the  adolescent  or 
of  the  ordinary  variety ;  but  although  a  few  cases  of  the  latter 
have  been  recorded,  I  have  not  myself  seen  an  example  of  it 
in  an  ament.  Accepting  the  view  that  syphilis  is  the  most 
common  cause,  one  would  suppose  that  the  state  of  the  nervous 
system  of  these  persons  would  render  them  particularly  liable 
to  its  action  should  they  become  infected  ;  possibly,  however, 


3i8  Mental  Deficiency 

the  explanation  of  the  comparative  infrequency  of  the  ordinary 
variety  of  general  paralysis  in  aments  may  be  that  they  are  not 
so  much  exposed  to  the  chances  of  syphilitic  infection. 

In  my  cases  the  symptoms  first  made  their  appearance 
between  the  ages  of  fourteen  and  nineteen  years,  all  the  patients 
being  well-marked  aments.  In  three  of  them  delusions  of 
persecution  were  present,  accompanied  at  one  time  by  attacks 
of  mania,  at  another  by  profound  depression  with  attempts  at 
suicide.  In  the  other  three  cases  the  mental  disturbance  con- 
sisted of  violent  emotional  storms.  These  conditions  persisted 
with  occasional  exacerbations  and  remissions  for  from  one  to 
two  years,  when  signs  of  dementia  appeared.  Several  of  these 
cases  have  already  been  described  in  the  account  of  syphilitic 
amentia. 

Epileptic  Insanity. — Many  feeble-minded  and  imbecile  epi- 
leptics are  exceedingly  irritable  and  liable  to  outbreaks  of  furious 
passion,  and  a  considerable  number  develop  insanity  just  the 
same  as  do  ordinary  epileptics.  There  are  no  special  features, 
and  the  tendency  is  usuaUy  to  early  dementia. 

Insanity  in  Imbeciles  and  Idiots. — Insanity  occurs  in  the 
severer  as  well  as  in  the  milder  grades  of  amentia,  and  it  may 
take  the  form  of  excitement  or  depression.  It  follows,  however, 
from  the  very  imperfect  mental  development  of  these  persons, 
that  the  disturbance  is  less  often  of  an  ideational  than  emo- 
tional character ;  it  is  also  usually  of  shorter  duration  than  in 
the  case  of  the  mild  aments.  Most  insane  attacks  in  pronounced 
imbeciles  and  idiots  take  the  form  of  sudden  and  violent 
maniacal  attacks.  During  these  the  child  or  youth  will  rash 
about,  making  hideous  noises,  overturning  or  smashing  every- 
thing in  his  way,  animate  as  well  as  inanimate,  and  often  dashing 
himself  with  great  violence  against  walls,  doors,  and  articles 
of  furniture  which  he  cannot  displace.  Such  attacks  are  liable 
to  recur  at  more  or  less  frequent  intervals. 

Illustrative  Cases. 

Case  i.  Feehle-mindedness ;  Attack  of  Acute  Mania  with 
Delusions  lasting  Six  Weeks;  Recovery  ;  Discharge. — C.  H.  C. 
a  feeble-minded  youth  with  several  well-marked  stigmata  of 
degeneracy ;  said  to  have  always  been  very  excitable ;  no  regular 


Insane  Aments  319 

employment.  Admitted  to  the  asylum,  aged  sixteen,  with 
acute  mania  of  three  weeks'  duration.  He  had  suddenly  become 
noisy  and  sleepless,  throwing  himself  into  strange  attitudes, 
utterly  irrational  in  his  conversation,  shouting  out  "  God  save 
the  Queen,"  and  asking  to  be  allowed  to  fight  the  Boers  ;  alter- 
nating with  this  he  was  tearful  and  anxious,  with  deltisions  of 
being  constantly  followed  by  policemen,  and  by  boys  who  called 
**  Thief  !"  after  him.  He  was  in  a  state  of  restless  agitation, 
begging  for  the  door  to  be  kept  locked.  For  a  week  after  admis- 
sion to  the  asylum  he  remained  in  this  excited  condition  day  and 
night,  and  it  was  quite  impossible  to  control  him.  He  was  terrified 
of  the  other  patients,  thinking  they  were  all  trying  to  strangle 
him.  After  a  week  he  gradually  became  quieter,  and  at  the 
end  of  two  months  had  become  so  quiet  and  well-behaved  that 
he  was  able  to  be  discharged. 

Case  2.  Feeble-mindedness ;  Attack  of  Acute  Mania  with  Delu- 
sions and  Hallucinations,  subsiding  in  Two  Months  ;  Subsequent 
Recurrences  for  Two  Years  ;  Signs  of  Dementia. — A.  C,  male, 
aged  twenty-five  years.  Has  always  been  backward,  and  never 
J^arnt  to  read  or  write.  After  leaving  school  earned  a  few 
shillings  weekly  by  doing  odd  jobs,  but  had  no  regular  employ- 
ment. Apt  to  behave  queerly  at  times  from  early  boyhood, 
and  on  several  occasions  disappeared  from  home  for  two  or 
three  days.  At  the  age  of  twenty-four  began  to  attend  music- 
halls  frequently,  and  shortly  afterwards  became  exceedingly 
strange  in  his  manner  ;  he  refused  to  do  any  work,  and  spent 
most  of  his  time  standing  at  the  open  window  talking  to  people 
he  imagined  he  saw.  Much  of  his  conversation  was  about  one 
"Flo  Arnold,"  whom  he  wished  to  marry,  for  which  purpose 
he  said  he  had  taken  £2  out  of  the  bank.  He  gradually 
became  quarrelsome,  and  finally  violent  and  acutely  maniacal, 
and  had  to  be  sent  to  the  asylum.  This  condition  of  mania, 
with  delusions  and  aural  hallucinations,  lasted  for  two  months, 
after  which  he  became  quieter.  He  has  now  been  in  the  asylum 
for  nearly  two  years.  He  is  subject  from  time  to  time  to  sudden 
outbursts  of  maniacal  excitement,  lasting  from  a  few  hours  to 
several  da>'s  ;  these  are  probably  due  to  delusions,  although 
none  can  be  ascertained.  He  shows  indications  of  the  onset 
of  dementia. 


520  Mental  Deficiency 

Case  3.  Feehle-mindedness  ;  Attack  of  Acute  Mania,  aged 
Sixteen,  passing  into  a  Condition  of  Recurrent  Insanity  ;  no 
Dementia  after  Three  Years. — A.  F.,  female.  "  Always  simple 
from  quite  a  child."  Left  school  aged  twelve,  being  only  in 
second  standard  ;  afterwards  in  a  training  home  ;  very  bad- 
tempered  and  addicted  to  smashing  windows  ;  sent  home  after 
three  years,  as  they  found  they  could  do  nothing  with  her.  At 
the  age  of  sixteen  she  became  so  violent  that  she  had  to  be 
removed  to  the  asylum,  having  previously  hurled  a  cooper's 
hammer  at  a  man  and  thrown  a  heavy  padlock  at  a  woman. 
She  remained  in  a  condition  of  maniacal  excitement  for  three 
months,  with  an  occasional  short  interval  of  comparative  calm. 
During  one  of  these  I  asked  her  why  she  behaved  so  violently  ; 
she  said  something  came  over  her  and  she  felt  she  "  must  do  it." 
In  the  next  three  months  she  became  much  quieter,  and  for  the 
following  live  months  she  remained  silent  and  gloomy,  refusing  to 
have  anything  to  do  with  the  other  patients  ;  then  she  relapsed 
into  a  state  of  restless  excitement  lasting  for  a  month,  followed 
by  another  period  of  depression.  She  is  now  nineteen  years  of 
age,  having  been  in  the  asylum  three  years.  She  is  at  times 
fairly  quiet  and  does  a  little  ward  work,  but  is  very  untrust- 
worthy, and  liable  to  sudden  outbursts  of  maniacal  excitement 
with  destructiveness  ;  she  is  highly  emotional  and  unstable, 
bursting  into  fits  of  tears  or  laughter  without  any  apparent 
cause.     There  are  no  indications  of  dementia. 

Case  4.  Feehle-mindedness  ;  Attack  of  Acute  Mania,  aged 
Sixteen  ;  Constant  Recurrences,  at  Times  accompanied  by  Delu- 
sions ;  under  Observation  Four  Years ;  no  Improvement. — R.  D., 
female.  Very  backward  at  school  ;  left  aged  thirteen  and 
went  to  service,  but  was  so  liable  to  what  her  mother  calls 
"fits  of  temper"  that  she  could  not  keep  any  situation  more 
than  a  few  months  ;  altogether  she  had  fourteen  situations 
in  less  than  three  years.  At  the  age  of  sixteen  she  be- 
came so  violent  that  she  was  sent  to  the  asylum.  On  admis- 
sion she  was  in  a  state  of  acute  mania,  screaming,  shouting, 
singing,  and  resisting  all  attempts  to  keep  her  in  bed  ;  she  also 
threatened  to  cut  her  throat.  This  condition  lasted  for  a  few 
days  after  admission  ;  she  then  became  quieter,  and  by  the  end 
of  a  fortnight  was  doing  some  work  in  the  wards.  Within  a 
month  she  had  a  relapse  exactly  similar  to  the  first  attack.     She 


Insane  Aments  321 

is  now  twenty  years  of  age,  and  has  been  in  the  asylum  four 
years.  At  times  she  is  quiet,  well-behaved,  and  answers  ques- 
tions readily  and  pleasantly  ;  it  is,  however,  quite  impossible  to 
depend  upon  her,  and  she  is  subject  from  time  to  time  to  sudden 
outbreaks  of  excitement,  in  which  she  becomes  most  abusive, 
uses  the  foulest  language,  and  violently  attacks  anyone  who 
may  be  in  her  way.  These  outbursts  last  for  three  or  four  days 
and  nights ;  as  a  rule,  they  seem  to  be  purely  emotional  storms, 
but  in  some  of  them  delusions  are  present,  generally  to  the  effect 
that  the  medical  officers  and  the  nurses  are  trying  to  cut  off  her 
head  or  to  torture  her  in  various  ways. 

Case  5.  High-grade  Imbecile  ;  Attack  of  Acute  Mania  subsiding 
in  Three  Months,  followed  by  Frequent  Recurrences ;  under 
Observation  for  Seven  Years  without  any  Improvement. — E.  5., 
female.  Simple-minded  from  birth  ;  did  not  get  on  at  school ; 
subsequently  kept  at  home  to  help  mother,  "  as  she  did  not 
seem  to  have  enough  sense  to  go  out  to  work  "  ;  was  at  times 
very  troublesome,  and  caused  much  annoyance  by  suddenly 
rushing  into  the  neighbours'  houses.  At  the  age  of  sixteen 
became  so  restless  and  excitable  that  they  could  do  nothing  with 
her,  and  sent  her  to  the  asylum.  The  medical  certificate  states 
"  she  exhibits  undue  mental  excitement,  talks,  sings,  shouts, 
and  laughs  immoderately,  and  behaves  in  an  insane  manner  ; 
very  restless,  imagines  the  attendants  to  be  her  former  school- 
teachers, and  seems  altogether  too  excited  to  control  herself 
and  talk  sensibly."  This  acute  condition  gradually  abated,  and 
by  the  end  of  three  months  she  had  become  quiet  and  able  to 
do  work  ;  two  months  later  she  relapsed,  again  becoming  excited 
noisy,  and  destructive  day  and  night,  in  which  state  she  remained 
for  three  weeks,  then  becoming  quiet  and  industrious  again. 
She  has  now  been  in  the  asylum  seven  years,  has  ceased  to  do 
any  work,  and  is  subject  to  frequent  acute  outbreaks  of  noisy 
aggressiveness.  In  some  of  these  attacks  delusions  are  present ; 
thus,  a  short  time  ago  she  stated  that  she  had  given  birth  to 
a  child,  which  had  been  stolen  from  her  in  the  night.  She 
is  very  impulsive,  and  on  one  occasion,  seeing  a  pail  of  water 
standing  in  the  ward,  she  suddenly  plunged  her  head  into 
it.  She  is  becoming  very  untidy  in  her  dress  and  personal 
appearance,  though  there  are  as  yet  no  other  indications  of 
dementia. 

21 


322  Mental  Deficiency 

Case  6.  Medium-grade  Imbecile  ;  Attack  of  Acute  Mania, 
aged  Fourteen ;  Condition  'practically  unchanged  at  the  End  of 
Six  Months. — C.  R.,  female.  Never  passed  first  standard  at 
school ;  subsequently  kept  at  home  ;  could  never  be  depended 
upon ;  and  from  nine  years  of  age  has  been  at  times  very 
violent  and  addicted  to  using  disgusting  language.  She  had 
to  be  sent  to  the  asylum  at  the  age  of  fourteen,  and  on  admis- 
sion was  in  a  state  of  mania,  chattering  to  herself  and  singing 
or  shouting  the  whole  day.  At  times  destructive  and  aggres- 
sive ;  very  restless  at  night.  She  has  now  been  in  the  asylum 
for  six  months,  and  on  the  whole  there  is  very  little  improvement. 
She  is  occasionally  fairly  quiet  and  rational,  but  as  a  rule  she  is 
raging  up  and  down  the  wards  singing,  shouting,  and  swearing 
at  the  other  patients.  The  charge-nurse  says  she  is  her  most 
troublesome  patient. 

Case  7.  Feeble-mindedness ;  Attack  of  Melancholia  with  Hal- 
lucinations and  Delusions,  passing  into  a  Condition  of  Recurrent 
Insanity  ;  Signs  of  Dementia  in  Six  Years. — C.  -D.,  male.  He 
could  never  learn  arithmetic  at  school,  as  the  master  said  his 
**  brain  was  too  weak."  Used  to  behave  very  oddly  at  times. 
After  leaving  school  was  employed  in  a  bootshop.  At  the  age 
of  sixteen  he  was  frightened  by  a  large  black  dog,  and  shortly 
afterwards  became  much  depressed,  gradually  passing  into  a 
condition  of  melancholia.  On  admission  to  asylum  he  was  found 
to  have  aural  and  visual  hallucinations  with  delusions.  He 
thought  he  was  surrounded  and  threatened  by  black  men  ;  he 
said  that  he  was  afraid  he  was  going  to  be  killed  in  the  China 
War,  and  that  God  told  him  to  kill  himself.  For  several  days 
he  was  restless  and  anxious,  afterwards  becoming  dull,  listless, 
lethargic,  and  a  confirmed  masturbator  ;  he  would  occasionally 
waken  out  of  this  stuporose  condition  to  become  aggressive  and 
violent.  Four  years  after  admission  he  had  so  much  improved 
that  he  was  discharged  to  his  friends,  only  to  be  readmitted  six 
weeks  later,  as  they  found  it  impossible  to  manage  him.  He  is 
now  twenty- two  years  of  age,  and  is  still  in  the  asylum,  being 
idle,  and  as  a  rule  dull  and  depressed  and  constantly  muttering 
to  himself  ;  occasionally  destructive  and  aggressive  ;  signs  of 
dementia  are  apparent. 

Case  8.  Medium-grade  Imbecile;  Attack  of  Melancholia  with 
Attempted    Suicide  ;  Recovery  in    Four  Months  ;  Relapse  Eight 


Insane  Ainents  323 

Months  afterwards  ;  now  again  recovering. — T.  K.,  male.  Mental 
deficiency  noticed  from  early  childhood  ;  incapable  of  learning 
at  school ;  no  work  subsequently  ;  never  earned  any  money. 
Gave  much  trouble  to  his  parents,  being  "  very  bad-tempered," 
and  frequently  wandering  away  from  home.  At  sixteen  years 
of  age  became  much  depressed,  and  attempted  suicide  by  taking 
carbolic  acid.  On  admission  into  asylum  was  wretched  and 
tearful,  saying  that  he  wanted  to  die,  and  there  was  no  reason 
why  he  should  live.  He  gradually  became  brighter  and  even 
cheerful,  and  a  month  after  admission  was  able  to  work  out  of 
doors ;  the  improvement  continued,  and  he  was  discharged  in 
four  months.  Eight  months  later  he  was  readmitted,  having 
been  found  by  a  policeman  battering  his  head  against  some  iron 
railings.  On  the  way  to  the  station  he  said  that  he  would  kill 
either  himself  or  his  father,  the  latter  stating  that  he  had  been 
violent  and  had  attempted  to  cut  his  (the  father's)  throat.  He 
was  profoundly  depressed,  thought  he  heard  voices,  and  that 
people  had  conspired  to  kill  him.  At  the  present  time  he  has 
been  in  the  asylum  four  months.  He  is  still  depressed  and 
solitary,  but  on  the  whole  decidedly  brighter,  doing  a  little  work, 
and  appears  to  have  lost  his  delusions. 

The  following  case  of  General  Paralysis  in  an  Adult  Ament  is 
recorded  by  Dr.  Cappelletti  :* 

The  patient,  a  female  imbecile  aged  fifty-four  years,  was  turned 
out  of  her  home  by  her  brother,  and  came  to  great  want  ;  she  was 
taken  into  the  asylum  in  a  maniacal  condition.  She  had  a  small* 
asymmetrical  skull,  tremor  of  tongue,  face,  and  extremities, 
hesitating  and  tremulous  speech,  wide,  unequal  pupils  which  only 
reacted  feebly  to  light  and  accommodation.  No  signs  of  syphilis 
on  the  body.  Mental  condition  exalted,  with  grandiose  ideas. 
Death  occurred  after  two  years  in  consequence  of  apoplectiform 
attacks.  Post-mortem  examination  showed  thickening  of  the 
dura  and  pia,  with  adhesions  and  cortical  erosions.  Small 
frontal  lobes,  asymmetrical  hemispheres,  and  a  narrow  grey 
substance.     The  basal  arteries  were  atheromatous. 

The  author  refers  to  two  other  similar  cases  which  have  been 
described,  and  in  a  subsequent  note  states  that  the  asylum 
register  at  Ferrara  shows  the  existence  of  a  fourth. 

♦  Neurolog.  Centralbl.,  1898,  p.  558. 

21 — 2 


CHAPTER  XVIII 

DIAGNOSIS  AND  PROGNOSIS 

The  physician  who  is  consulted  with  regard  to  a  possibly  mentally 
deficient  person  will  be  expected  to  answer  three  questions. 
First,  Is  amentia  really  present  ?  Secondly,  To  what  extent 
can  it  be  improved  ?  Thirdly,  What  is  the  form  of  t^tatment 
to  be  adopted  ?  These  three  matters  of  diagnosis,  prognosis, 
and  treatment  will  be  dealt  with  in  the  present  and  succeeding 
chapters. 

Diagnosis. 

The  question  of  diagnosis  has  already  been  considered  to  a 
great  extent  in  previous  chapters,  particularly  that  referring  to 
mentally  defective  children  ;  it  will,  however,  be  convenient  to 
summarize  the  chief  points  to  which  attention  must  be  paid. 

In  infants  the  symptom  which  usually  first  attracts  atten- 
tion, and  which  causes  the  parents  to  seek  advice,  is  the  presence 
of  abnormal  nerve  signs.  Briefly,  there  is  either  a  state  of 
torpid,  listless  indifference,  so  that  the  child  makes  no  attempt 
to  suck,  does  not  look  about  him,  does  not  cry,  and,  in  fact,  is 
generally  lacking  in  spontaneity  ;  or  the  reverse  of  this  con- 
dition is  present,  the  child  being  abnormally  restless,  always 
crying  and  tossing  about,  and  getting  hardly  any  sleep.  In 
cases  of  severe  amentia,  one  or  other  of  these  states  is  generally 
present  during  the  first  twelve  months.  The  latter,  however, 
attracts  most  attention,  for  mothers  are  inclined  to  look  upon 
the  former  as  merely  an  excessive  amount  of  "  goodness,"  and, 
at  first,  to  congratulate  themselves  accordingly. 

But  these  conditions,  although  abnormal-  and  indicative  of 
brain  disturbance  of  some  kind,  are  not  diagnostic  of  amentia. 

324 


Diagnosis  and  Prognosis  325 

They  may  result  from  inadequate  or  improper  feeding,  causing 
general  malnutrition,  or  from  some  more  serious  bodily  disease. 
The  first  care  of  the  physician,  therefore,  must  be  to  make  a 
thorough  physical  examination  of  the  child,  and  particularly 
to  exclude  such  morbid  states  as  anaemia,  rickets,  malnutrition, 
bone  caries,  the  various  forms  of  tuberculosis,  otitis,  meningitis' 
cerebral  abscess,  and  reflex  causes  of  nervous  irritation. 

Having  done  this  and  ascertained  that  there  is  no  bodily 
condition  responsible  for  the  nervous  abnormality,  he  has  still 
to  decide  whether  he  is  dealing  with  a  child  preternaturally  dull 
and  stolid,  with  one  unduly  excitable  and  neurotic,  or  with  one 
who  is  really  mentally  deficient.  Here  the  family  history  and 
the  presence  of  stigmata  of  degeneracy  or  features  peculiar  to 
certain  varieties  of  amentia  will  be  of  great  value. 

If  with  either  of  these  abnormal  nervous  states  there  is  asso- 
ciated a  pronounced  morbid  heredity,  there  is  a  strong  prob- 
ability that  the  child  will  turn  out  to  be  mentally  deficient. 
If  stigmata  of  degeneracy  are  present  in  addition,  this  prob- 
ability is  greatly  increased,  and  a  diagnosis  may  thus  be  possible 
in  the  early  months  of  life.  If  special  features  exist,  such  as 
the  abnormally  small  skull  of  the  microcephalic,  the  peculiar 
physiognomy  of  the  Mongol  or  cretin,  the  changes  in  the  fundus 
of  infantile  cerebral  degeneration,  or  even  marked  paralysis,  the 
diagnosis  may  be  made  with  certainty. 

But  even  if  stigmata  be  absent,  and  the  child's  condition  be 
plainly  due  to  brain  disease  without  neuropathic  predisposition,  it 
must  still  be  remembered  that  serious  disease  of  the  brain  occur- 
ring in  early  life  may  terminate  in  secondary  amentia,  if  death 
does  not  previously  end  the  scene  ;  whilst  this  possibility  is 
greatly  increased  in  the  presence  of  morbid  heredity.  The 
association  of  continuous  epileptic  convulsions  with  any  of 
these  conditions  greatly  adds  to  the  unfavourable  outlook  as 
to  the  future  mental  development. 

In  cases  seen  somewhat  later — say  during  the  years  of  child- 
hood— there  is  less  difficulty  in  arriving  at  a  diagnosis.  Not 
only  is  there  the  great  advantage  of  a  longer  life  history,  and 
consequently  more  information  forthcoming  as  to  general 
behaviour  ;  but,  since  by  the  age  of  five  or  six  years  the  normal 
child  has  made  considerable  intellectual  advance,  the  arrears 


326  Mental  Deficiency 

of  the  mentally  deficient  one  at  this  age  are  by  contrast  much 
more  apparent.  Idiocy,  imbecility,  and  pronounced  feeble- 
mindedness can  now  hardly  fail  to  be  detected,  and  the  chief 
difficulty  experienced  will  be  with  regard  to  the  mildest  degrees 
of  intellectual  or  moral  defect.  It  is  still  necessary  to  remember 
that  amentia  may  be  simulated  by  bodily  ill-health  or  disease, 
IS  weU  as  by  delayed  development  or  dullness  of  intellect  not 
amounting  to  defect.  These  conditions  have  already  been 
fully  referred  to  in  treating  of  mentally  deficient  children. 

At  a  still  later  age,  or  in  the  adult,  it  is  again  practically  only 
the  milder  cases  which  give  rise  to  any  real  difficulty  of  diagnosis. 
Amongst  the  wealthy  classes,  or  where  property  is  concerned, 
such  cases  may  form  the  subject  of  a  judicial  inquiry,  and  the 
greatest  care  must  be  taken  in  arriving  at  and  stating:  an  opinion. 
This  will  be  based  upon  a  careful  examination  of  The  patient's 
mental  capacity,  as  revealed  by  his  manner,  conversation,  and, 
if  necessary,  the  way  in  which  he  discharges  some  test  com- 
missions entrusted  to  him,  as  well  as  by  a  consideration  of  his 
previous  general  behaviour  ;  also  by  attention  to  the  presence 
of  stigmata  of  degeneracy  and  a  neuropathic  family  history, 
as  indicative  of  primary  amentia,  or  the  well-marked  history 
and  signs  of  brain  disease  which  usually  accompany  secondary 
amentia. 

The  question  which  has  to  be  answered  is.  Is  this  person 
capable  of  competing  on  equal  terms  with  his  normal  fellows, 
or  of  managing  himself  and  his  affairs  with  ordinary  prudence  ?  If 
he  be  not  thus  capable,  then  he  is  probably  suffering  from  mental 
deficiency ;  but  such  a  condition  may  also  be  due  to  insanity  or 
early  dementia,  and  these  will  require  to  be  excluded.  In  most 
cases  attention  to  the  previous  history  and  to  the  nature  and 
motive  (or  absence  of  motive)  of  the  acts  committed  or  omitted, 
as  the  case  may  be,  will  settle  the  point.  It  is,  however,  to  be 
remembered  that,  whilst  delusions  are  common  in  both  insanity 
and  dementia,  they  may  also  occur  in  aments.  In  fact,  insanity 
with  delusions  is  a  not  infrequent  complication  of  mild  mental 
deficiency. 

A  person  who  recklessly  distributes  his  possessions  or  im- 
poverishes himself  by  expending  large  sums  of  money  on  objects 
for  which  he  has  not  the  slightest  use,  under  the  delusion  that 


K 

H 


Diagnosis  and  Prognosis  327 

he  is  acting  as  the  almoner  of  the  Almighty  or  is  the  richest  man 
on  earth,  is  probably  insane  or  demented.  But  if  he  does  these 
things  in  consequence  of  an  inability  to  realize  the  value  of 
money,  and  his  purchases  are  such  as  would  only  bring  delight  to 
a  child  ;  if  he  shows  a  complete  incapacity  for  business  manage- 
ment, an  undue  credulity,  and  a  lack  of  sense  of  responsibility  ; 
if,  further,  he  is  content  to  be  left  with  the  barest  necessities 
of  life,  whilst  his  patrimony  is  plundered  by  his  acquaintances 
under  his  very  eyes,  he  may  justly  be  regarded  as  mentally 
deficient. 

Perhaps  the  greatest  difficulty  of  all  in  deciding  whether 
amentia  is  present  or  not  is  experienced  in  certain  cases  present- 
ing moral  defect  or  perversion,  and  which  come  before  the  criminal 
courts.  High-grade  aments,  non-defective  but  mentally  un- 
stable persons,  and  thriftless,  irresponsible  ne'er- do -we  41s  and  f 
was^rels^  form  a  very  large  proportion  of  that  section  of  man-  4 
kind  which  is  on  the  down-grade.  A  large  number  of  them  are  .:^ 
liable  to  commit  offences  against  law  and  society  ;  indeed,  it 
is  from  these  classes  that  the  great  majority  of  our  criminals  and 
paupers  are  drawn.  It  is  here  that  a  decision  as  to  whether 
mental  deficiency  is  or  is  not  present  may  be  extremely  difficult. 
It  is  impossible  to  lay  down  any  rules,  for  each  case  must  be 
considered  on  its  merits  ;  but  I  think  that  attention  to  the  family 
history,  the  life  history  and  previous  behaviour  of  the  patient, 
together  with  a  careful  examination  of  his  bodily  and  mental 
condition,  will  usually  enable  a  decision  to  be  made. 

Prognosis. 

Having  ascertained  that  amentia  is  really  present,  the 
physician  will  next  be  called  upon  to  say  to  what  extent  it  may 
be  remedied  by  treatment. 

Until  sixty  years  ago  cases  of  pronounced  mental  deficiency 
were  considered  to  be  absolutely  and  hopelessly  beyond  any 
possibility  of  amelioration.  But  in  1846  Dr.  Edouard  Seguin* 
demonstrated  to  the  world  the  capacity  possessed  by  many  of 
these  persons  for  considerable  improvement  under  patient  and 
systematic  training,  and  since  then  the  pendulum  has  gradually 

*  Edouard  Seguin,  "Idiocy,  and  its  Treatment  by  the  Physiological 
Method,"  New  York,  1866. 


328  Mental  Deficiency 

swung  to  the  other  extreme.  At  the  present  day  the  training 
of  the  mentally  deficient  occupies  a  more  or  less  important  place 
in  the  social  system  of  most  civilized  countries,  and  it  is  even 
questionable  if  there  be  not  a  tendency  to  overestimate  the 
educational  possibilities,  and  to  think  the  machine  only  needs 
to  be  suiUciently  elaborate  in  order  that  the  entering  idiot  may 
emerge  a  person  of  normal  intelligence. 

Both  these  views  are  wrong,  and  are  to  be  deprecated.  On 
the  one  hand,  there  are  comparatively  few  cases  so  bad  that 
they  cannot  be  improved  to  some  extent,  if  only  in  habits 
of  cleanliness  and  the  curtailing  of  destructive  and  dangerous 
propensities.  On  the  other  hand,  no  case  of  real  amentia  (with 
the  exception  of  cretinism)  ever  becomes  cured.  However  mild 
it  may  be,  some  defect  will  always  remain,  ail!ft  this  will  render 
competition  on  an  equal  footing  with  the  normal  population 
impossible. 

And  here  it  is  necessary  to  enter  a  protest  against  the  practice 
adopted  by  some  medical  men,  of  telling  the  parents  that  the 
child  will  "  grow  out  of  it,"  or  that  he  will  be  "  all  right  when 
he  is  seven,"  or  "  fourteen,"  or  "  twenty-one."  In  some  cases 
this  is  done  from  ignorance  of  what  amentia  really  is,  in  others 
from  a  benevolent  but  mistaken  idea  of  sparing  the  parents' 
feelings.  Where  the  physical  condition  of  the  patient  is  such 
that  death  cannot  be  long  delayed,  the  disquieting  knowledge 
that  idiocy  is  present  may  perhaps  be  withheld  ;  but  in  other 
cases  the  interests  of  the  patient  demand  that  the  parents 
should  be  told  the  truth,  for  much  of  the  early  training  so  neces- 
sary for  improvement  will  be  in  their  hands.  I  have  known 
children  dragged  about  from  doctor  to  doctor  and  from  quack 
to  quack  in  the  vain  hope  of  seeing  that  change  which  had  been 
confidently  foretold,  but  which  never  came.  I  have  known ' 
many  pounds  spent  on  nostrums,  electrical  and  galvanic  appli- 
ances, whilst  the  child  was  rapidly  deteriorating  for  want  of 
systematic  training  ;  but  I  have  rarely  met  parents  who  were 
other  than  grateful,  though  sad,  when  the  real  truth  was  kindly 
told  them.  Few  people  like  living  in  a  fool's  paradise,  and  in 
this  case  it  is  not  a  paradise,  for  there  is  often  the  lurking 
suspicion  that  something  is  really  wrong,  and  that  the  practi- 
tioner does  not  understand  the  case. 


Diagnosis  and  Prognosis  329 

To  what  extent,  then,  may  the  patient  be  improved  by  treat- 
ment ?  No  absolute  forecast  can  be  given,  but  attention  to 
certain  considerations  regarding  the  form,  variety,  and  degree 
of  amentia  will  enable  a  tolerably  accurate  prognosis  to  be  given 
in  most  cases. 

Prognosis  of  the  Forms  of  Amentia. — As  a  rule,  cases  of  primary 
amentia  are  much  more  capable  of  improvement  than  are  those 
of  the  secondary  form.  In  other  words,  contrary  to  what  would 
be  expected  from  their  appearance,  the  stunted,  misshapen,  and 
often  repulsive -looking  victims  of  morbid  heredity  are  more 
responsive  to  training  than  are  the  well-grown,  and  often  well- 
favoured,  sufferers  from  accidental  injury  or  disease  of  the  brain. 
This  dictum  was  enunciated  by  Langdon  Down  many  years  ago, 
in  the  words  that  the  prognosis  is  favourable  "  inversely  as  the 
child  is  comely,  fair  to  look  upon,  and  winsome,"  and  experience 
has  fully  confirmed  its  general  truth.  The  explanation  of  this 
apparent  anomaly  is  that  in  the  latter  group  we  have  to  do 
with  destructive  lesions,  whose  course  is  often  progressive,  and 
which,  by  inducing  a  general  disturbance  of  the  whole  function 
of  the  brain,  make  education  impossible.  In  the  former,  on  the 
other  hand,  although  neuronic  development  is  irregular  and 
incomplete,  there  is  often  no  actual  disease. 

Prognosis  in  Different  Varieties. — The  foregoing  statement, 
however,  is  not  rigidly  exact,  for  the  result  is  to  some  extent 
dependent  upon  the  variety  of  amentia  present.  The  prognosis 
of  the  respective  varieties  may  be  summarized  as  follows  : 
^  In  simple  primary  amentia  the  result  is  hopeful  or  the  reverse 
in  direct  proportion  to  the  degree  of  deficiency  and  the  presence 
of  epilepsy  or  paralysis. 

In  microcephalics,  with  the  exception  of  extreme  instances,  a 
considerable  amount  of  improvement  may  be  predicted,  and  the 
patient  may  eventually  become  capable  of  many  simple  routine 
tasks  not  requiring  thought.  But  he  will  always  be  markedly 
deficient  in  mental  capacity. 

In  Mongolians  the  prognosis  is,  generally  speaking,  directly 
proportionate  to  the  intensity  of  the  bodily  signs.  The  milder 
cases,  as  a  result  of  appropriate  training,  may  almost  come 
to  pass  muster  with  their  brothers  and  sisters  ;  but  they  will 
always  require  some  one  to  manage  their  affairs.     Many  of  the 


33^  Mental  Deficiency 

more  pronounced  cases,  even,  can  be  taught  to  do  some  useful 
work  in  the  garden  or  on  the  farm. 

In  cases  of  secondary  amentia  due  to  toxic  or  vascular  disease 
of  the  brain,  the  prognosis,  as  already  remarked,  is  on  the  whole 
decidedly  less  favourable  than  in  primary  aments  ;  but  it  differs 
very  greatly  according  to  the  nature  of  the  lesion.  In  cases  in 
which,  after  the  infliction  of  the  damage,  the  pathological  lesion 
ceases  to  progress,  and  serious  secondary  anatomical  changes  are 
not  induced,  the  prognosis  is  tolerably  good,  always  provided 
that  appropriate  training  is  begun  sufficiently  early.  Many  cases 
of  birth  injury  and  purely  vascular  lesions  occurring  in  very  early 
life  are  of  this  nature,  and  the  improvement  is  probably  brought 
about  by  neuronic  compensation.  Many  of  these  persons  who 
suffer  from  severe  paralysis  even  may  be  educated  to  read,  write, 
sum,  and  do  mechanical  work  with  surprising  dexterity ;  but  there 
is  usually  a  little  childishness,  a  want  of  judgment  regarding  the 
affairs  of  life,  and  an  inability  to  make  headway  against  com- 
petition. Dr.  Shuttle  worth*  mentions  such  a  case  presenting 
right  hemiplegia  with  athetosis  attributed  to  injury  at  birth, 
who  was  admitted  into  the  Royal  Albert  Asylum  at  the  age  of 
twelve  years.  "  In  spite  of  his  physical  drawbacks,  he  rapidly 
developed  graphic  abilities,  and  after  a  course  of  scholastic 
instruction  in  writing,  drawing,  reading,  etc.,  with  suitable 
physical  and  manual  exercises,  he  was  trained  to  woodwork  in 
the  joiner's  shop,  where  he  'gradually  attained  such  control  over 
his  irregular  movements  that  he  became  an  expert  workman, 
making  tables,  chests  of  drawers,  and  decorative  sideboards. 
He  showed  a  nice  taste  for  wood-carving,  and  ultimately  became 
so  skilful  in  it  that  he  is  now  employed  as  instructor  in  this  art. 
He  is  also  a  clever  scene-painter.  He  is  now  practically  ambi- 
dext^'ous,  his  right  hand  having  been  trained  to  be  serviceable." 

Iti  is,  of  course,  to  be  remembered  that  in  many  of  these  cases 
of  birth  paralysis  the  lesion  concerns  the  motor  centres  of  the 
brain  only,  the  child  subsequently  appearing,  but  not  in  reality 
being,  mentally  deficient  because  his  crippled  condition  has  pre- 
vented his  attendance  at  school. 

On  the  other  hand,  in  cases  where  the  lesion  is  active  or  induces 
progressive   pathological   changes,    the   prognosis   is    decidedly 

♦  G.  E.  Shuttleworth,  "Mental  Deficiency  in  Children,"  British  Journal 
of  Children's  Diseases,  March,  1904. 


Diagnosis  and  Prognosis  331 

unfavourable,  and  in  a  considerable  number  dementia  sooner  or 
later  supervenes.  The  majority  of  these  are  characterized  by 
.epileptiform  or  epileptic  convulsions. 

Amentia  due  to  epilepsy  is  decidedly  unfavourable,  being,  in 
fact,  one  of  the  most  hopeless  varieties.  For  epilepsy  which 
has  produced  amentia  will  probably  end  by  producing  dementia. 
In  other  cases  of  mental  deficiency,  in  which  epilepsy  is  a  com- 
plication and  not  the  cause,  it  is  still  a  highly  unfavourable  symp- 
tom, and  imposes  a  considerable  barrier  to  successful  education. 

In  sclerotic  amentia  the  most  hopeful  cases  are  those  in  which 
enlargement  of  the  skull  takes  place.  The  majority  of  cases  of 
pronounced  sclerosis  with  crania  of  normal  or  diminished  size 
die  before,  or  soon  after,  attaining  the  age  of  puberty. 

In  hydrocephalus  everything  depends  upon  the  course  of  the 
disease,  which  can  never  be  foreseen.  Rapidly  progressing  expan- 
sion of  the  skull  is  almost  invariably  fatal ;  but  in  cases  where  spon- 
taneous arrest  takes  place,  the  resulting  mental  impairment  may 
be  but  slight,  and  may  be  largely  remedied  by  suitable  training. 

In  syphilitic  amentia,  in  view  of  the  tendency  to  the  develop- 
ment of  general  paralysis,  the  outlook  is  decidedly  bad  ;  whilst 
in  infantile  cerebral  degeneration  it  is  hopeless. 

In  cretinism  the  prognosis  is,  on  the  whole,  dependent  upon 
tne  age  at  which  treatment  is  begun  and  the  persistence  with 
which  it  is  carried  out.  As  already  mentioned,  however,  it  is 
possible  that  other  factors  may  influence  the  result — e.g.,  the 
presence  or  absence  of  morbid  heredity. 

Amentia  due  to  isolation  or  sense  deprivation  is  curable  provided 
special  education  is  begun  sufficiently  early,  and  even  in  cases 
which  have  been  neglected  for  years  it  is  remarkable  what  results 
may  follow  patient  and  systematic  training. 

Prognosis  regarding  the  Degree. — Finally,  a  few  words  may  be 
said  with  regard  to  the  degree  of  amentia.  In  the  absence  of 
contra-indication,  such  as  epilepsy  or  the  special  pathological 
processes  just  mentioned,  the  amount  of  improvement  and  the 
final  result  will,  of  course,  be  dependent  upon  the  degree  of  initial 
defect.  This  cannot  always  be  gauged,  but  some  measure  of  it 
will  be  afforded  by  a  careful  comparison  of  the  physiological  and 
psychological  development  of  the  patient  with  that  of  a  normal 
child  of  corresponding  age.  Regarding  this,  reference  may  be 
made  to  the  Table  of  Normal  Developmental  Data  on  p.  364. 


CHAPTER  XIX 
TREATMENT  AND  TRAINING 

I.— MEDICAL  AND  SURGICAL  TREATMENT. 

There  is  no  drug  which  has  the  sHghtest  direct  or  specific  in- 
fluence upon  primary  mental  deficiency,  and,  we  may  safely 
assert,  there  never  will  be.  Considering  that  this  condition  is 
the  outcome  of  a  neuropathic  diathesis,  due  in  many  cases  to 
generations  of  antecedent  disease,  we  can  no  more  hope  to  relieve 
it  by  medicaments  than  we  can  hope  by  such  means  to  transform 
the  worn-out  tissues  of  age  into  the  virile  ones  of  youth,  or  to 
restore  life  to  the  dead. 

With  regard  to  secondary  amentia,  there  is  one  form,  cretinism, 
for  which  a  specific  exists.  It  may  even  subsequently  be  dis- 
covered that  there  are  other  varieties  of  secondary  amentia 
due  to  definite  qualitative  anomalies  of  blood-supply,  and  for 
these  the  corresponding  specific  may  also  be  found.  Possibly, 
as  already  mentioned,  some  cases  of  Mongolism  may  be  of  this 
nature.  But  if  such  cases  do  exist,  it  may  safely  be  stated  that 
they  are  exceedingly  rare,  and  in  the  great  majority  of  in- 
stan.ces  of  secondary  amentia,  as  well  as  of  primary,  drugs  have 
no  direct  influence.  Pituitary  and  thymus,  as  well  as  other 
glandular  extracts,  have  been  tried  without  the  slightest  avail  ; 
and  even  the  amentia  which  is  directly  due  to  syphilis  shows 
not  the  slightest  improvement  under  antisyphilitic  treatment. 

The  same  must  be  said  of  surgical  treatment.  When  the 
theory  was  propounded  that  microcephalus  was  due  to  prema- 
ture synostosis,  it  was  natural  that  the  surgeon  should  suggest 
relief  by  craniectomy.  During  the  year  1890,  and  for  a  time 
after,  a  considerable  number  of  operations  were  performed  by 

332 


Treatment  and  Training  333 

eminent  men,  chief  of  whom  may  be  mentioned  Lannelongue 
(Paris),  Victor  Horsley  (London),  and  Keen  (Philadelphia).  The 
cases  operated  upon  were  not  only  microcephalics,  but  included 
other  varieties  of  amentia.  The  mortality  was  exceedingly  high 
(about  25  per  cent.),  and  those  who  survived  showed  no  mental 
improvement.  It  is  not  surprising  that  the  operation  should 
have  gradually  been  abandoned  by  reputable  surgeons,  and  to-day 
it  is  practically  unheard  of.  It  was,  indeed,  founded  upon  a 
mistaken  notion  as  to  the  pathology  of  this  condition,  and  it 
may  be  said  that  to-day  operations  of  this  kind  upon  cases  of 
primary  amentia  are  absolutely  unjustifiable. 

The  case  is  somewhat  different  with  regard  to  certain  varieties 
of  secondary  amentia.  Where  there  is  no  morbid  heredity,  and 
where  there  is  clear  evidence,  or  even  a  reasonable  presumption, 
that  the  deficiency  is  due  to  fracture,  splintering  of  the  inner 
table,  or  other  conditions  causing  increased  cranial  pressure, 
then  not  only  is  operation  justifiable,  but  it  is  the  duty  of  the 
physician  to  advise  it  at  the  earliest  possible  moment,  and  before 
changes  have  been  induced  which  may  be  irreparable.  I  must 
confess,  however,  that  I  know  of  no  statistics  sufficiently  exten- 
sive to  show  the  results  of  operation  in  such  cases. 

Nevertheless,  it  is  not  to  be  assumed  that  medicine  or  surgery 
have  no  place  in  the  treatment  of  amentia.  This  is  far  from 
being  the  case,  for  mens  sana  in  corpora  sano  is  a  true  saying, 
and  medicine  and  surgery  can  do  much  to  promote  the  bodily 
well-being  of  these  persons.  I  am  no  advocate  for  the  systematic 
drenching  of  the  ament  with  drugs,  or  for  the  performance  upon 
him  of  operations  which  can  contribute  nothing  to  the  improve- 
ment of  his  body  or  mind  ;  but  it  cannot  be  doubted  that  con- 
ditions are  often  present  which  stand  in  the  way  of  efficient 
training  and  which  are  amenable  to  treatment ;  and  it  is  certain 
that  education  will  be  attended  with  most  success  when  every 
means  have  been  employed  to  place  the  body  in  the  best 
possible  condition. 

Before  systematic  education  is  begun,  therefore,  it  is  of  great 
importance  to  ascertain  the  existence  of  disease,  disorder,  or  de- 
formity, and  to  correct  the  same  by  appropriate  remedies,  if  such 
be  possible.  It  is  unnecessary  to  describe  all  the  diseases  and  ail- 
ments wkich  may  affect  the  mentally  deficient  child  ;  their  name 


334  Mental  Deficiency 

is  legion,  and  the  chief  of  them  have  already  been  referred  to  in 
previous  chapters.  It  may  be  stated,  however,  that  conditions 
which  particularly  call  for  treatment  are  adenoids,  enlarged  ton- 
sils, nasal  polypi,  cleft  palate,  carious  teeth,  errors  of  refraction, 
disease  of  the  ear,  phimosis,  hernia,  webbing  of  the  fingers,  etc. 
Troublesome  contractures  may  often  be  relieved  by  tenotomy, 
and  where  club-foot  is  present,  walking  may  be  greatly  improved 
by  suitable  surgical  boots.  Medical  treatment  is  called  for  in 
anaemia,  malnutrition,  and  many  disorders  of  the  circulatory, 

j  respiratory,  alimentary,  and  cutaneous  systems.  Troublesome 
constipation  is  best  met  by  attention  to  the  diet  and  the  adminis- 
tration of  cascara  sagrada.  Diarrhoea  is  often  caused  by  im- 
perfect mastication  or  unsuitable  fRod,  and  may  need  antiseptic 
or  astringent  treatment.  Extract  of  malt,  with  or  without  cod- 
liver-oil,  is  valuable  in  severe  malnutrition.  Epilepsy  is  best 
treated  by  a  careful  control  of  the  diet  and  daily  life ;  but  if  this 

•  fails,  the  frequency  and  severity  of  the  attacks  are  often  checked 
by  borax  and  the  bromides.  A  single  dose  of  the  latter  at  bed- 
time is  often  useful  in  allaying  the  undue  instability  so  common 
in  raany  of  the  milder  defectives.  Enuresis,  a  frequent  com- 
phcation,  is  best  treated  by  accustoming  the  child  to  evacuation 
at  regular  periods.  It  may  be  helped  by  withholding  all  fluid 
for  at  least  two  hours  before  retiring,  and  in  many  cases  a  few 
nightly  doses  of  one  of  the  bromides  will  serve  to  check  the  habit. 
In  addition  to  these  indications  for  special  treatment,  the 
food,  clothing,  exercise,  cleanliness,  and  general  hygiene  of  these 
persons  demand  the  closest  attention.  The  dietary  must  be 
on  a  liberal  scale,  but  plain,  and  excess  of  meat  must  carefully 
be  avoided.  Where  mastication  is  imperfect,  recourse  to  spoon 
food  is  often  necessary,  and  this  is  always  the  case  with  the  low- 
grade  idiots.  The  danger  of  asphyxia  from  the  impaction  of 
food  in  the  glottis  is  no  fancy,  and  many  cases  of  aspiration 
pneumonia  have  been  recorded.  Attention  to  the  clothing  is 
particularly  called  for  in  the  Mongolian  variety,  as  well  as 
in  other  patients  prone  to  catarrhal  and  circulatory  disturbances. 
In  the  cold  weather,  the  wearing  of  gloves  may  prevent  trouble- 
some chilblains.  Daily  exercising  and  bathing  must  always  be 
enforced,  and  the  greatest  care  must  be  taken  that  rooms  are 
sunny,   not   too   warm,   and  thoroughly  well   ventilated.     The 


Treatment  and  Training  ^?35 

marked  predisposition  which  many  of  these  persons  evince  to 
the  development  of  tuberculosis  must  be  kept  well  in  mind.  \ 

It  is  unnecessary  to  enter  any  further  into  the  details  of 
medical,  surgical,  and  hygienic  treatment,  since  the  principles 
are  the  same  in  these  as  in  ordinary  children.  The  only  point 
I  wish  to  insist  upon  is  that  mental  deficiency  is  often — in- 
deed, usually — accompanied  by  bodily  deficiency,  disorder,  and  i 
disease,  and  that  the  treatment  of  these  latter  is  an  essential 
prelude  to,  or  accompaniment  of,  the  training  of  the  mind. 


IL— EDUCATION. 
General  Principles. 

Having  done  our  best,  by  careful  attention  to  the  laws  of 
hygiene — aided,  where  necessary,  by  medicine  and  surgery — 
to  remove  any  likely  impediments  to  training,  and  to  bring 
the  mentally  deficient  child  into  the  best  possible  physical 
condition,  the  question  of  education  must  be  considered.  In 
the  following  pages  I  shall  deal  with  the  general  principles  upon 
which  such  should  be  based,  particularly  those  which  concern 
the  physician.  The  actual  pedagogic  methods  to  be  employed 
are  beyond  the  scope  of  this  work,  and,  for  the  most  part,  can 
only  be  acquired  by  practical  experience. 

Education  has  a  threefold  object.     First,  it  should  develop  '  • 
and  cultivate  all  the_  latent  potentialities  of  body  and  mind  to    . 
tKeir  tullest  extent  ;  secondly,  it  should  repress  or  eliminate  vices 
^jid^  faulty  modes  of  action  ;  thirdly,  it  should  supply,  if  possible,  3 
such  particular  instruction  as  will_fit  the  individual  for  some 
useful   form   of   WQik^'     In  other  words,  it  should  aim  at  im- 
parting knowledge   as  well    as    inculcating  wisdom.     The  two 
former  of  these  objects  are  educational  in  the  literal  sense  of  the 
word  ;  the  latter  may  be  looked  upon  as  technical  instruction. 

The  development  of  mind  takes  place  in  consequence  of  two 
influences  :  spontaneity,  or  an  inherent  tendency  of  the  brain 
cells  to  develop ;  and  stimulation  of  these  cells  by  external  im- 
pressions. The  brain  of  the  healthy  child  has  an  inherent 
potentiality  which  makes  it  to  a  certain  extent  independent  of 
its  environment ;  or  perhaps  I  should  rather  say  that  it  is  capable 


336  Mental  Deficiency 

of  utilizing  and  responding  to  any  surroundings,  within  ordinary 
limits,  in  which  it  may  be  placed.  A  little  friend  of  mine,  aged 
four  years,  reads  ''  Alice  in  Wonderland "  with  remarkable 
facility.  She  has  never  had  a  single  formal  lesson,  and  her 
knowledge  was  picked  up  solely  by  observing  letters  and  asking 
questions.  The  defective  mind  is  lacking  in  this  power.  ''  One 
of  its  chief  characteristics,  if  not  the  chief,  is  a  want  of  what 
may  be  termed  mental  aggressiveness  ;  consequently  its  develop- 
ment has  to  be  aided  and  encouraged  by  special  means.  At 
the  same  time,  the  deficient  power  of  control  often  gives  full 
play  to  the  lower  organic  feelings,  resulting  in  vices,  antisocial 
acts,  and  crimes.     These  tendencies  have  to  be  eliminated. 

TTntjl  qivty  yearsuago^Jihg  training  of  the  mentally,. deficient , 
where  such  was  attempted,  was  conducted  upon  no  logical 
method,  and  it  is  to  Dr.  Edouard  Seguih  that  we  oweThe  first 
clear  enunciation  of  the  principles  upon  which  it  should  be 
based.  In  his  words,  education  ''  consists  in  the  adaptation 
of  the  principles  of  physiology,  through  physiological  means 
and  instruments,  to  the  development  of  the  dynamic,  perceptive, 
reflective,  and  spontaneous  functions  of  youth."  By  the  pains- 
taking and  laborious  application  of  these  principles,  Seguin 
himself  demonstrated  the  remarkable  results  which  may  take 
place  even  in  apparently  hopeless  idiots  ;  and  upon  his  principles, 
extended  and  elaborated  by  the  work  of  Froebel  and  Pestalozzi, 
most  of  our  present  methods  are  based. 

The  method  of  applying  these  principles,  in  brief,  is  to  take 
each  "  function  "  or  "  faculty,"  each  physiological  system  of 
neurones,  and,  by  means  of  appropriate  and  carefully  arranged 
progressive  exercises,  to  develop  them  to  the  fullest  extent  of 
their  capacity.  I  do  not,  of  course,  mean  to  suggest  that  we 
can  isolate  and  develop  separately  each  "  function."  All 
portions  of  the  mental  apparatus  are  interdependent,  and 
education  is  a  general  process  which  simultaneously  concerns 
the  development  of  the  bodily  as  well  as  the  sensory,  motor, 
intellectual,  emotional,  and  moral  functions.  But  it  is  con- 
venient for  purposes  of  description  to  make  this  division,  and  it 
tends  to  emphasize  the  fact,  that  as  the  child's  development 
naturally  takes  place  in  a  regular  progressive  order,  so  must  the 
training  be  progressively  adapted  to  its  growing  needs. 


Treatment  and  Training  337 

In  many  cases  it  is  first  of  all  necessary  to  arouse  spontaneity. ' 
The  child  is  inert,  and  must  even  be  stimulated  to  play ;  until 
this  is  accomplished,  and  some  interest  is  aroused,  any  further 
training  is,  of  course,  impossible.  Having  succeeded  in  arousing 
some  degree  of  initiative  by  means  of  romping  play,  this  is 
gradually  replaced  by  more  definite  games,  and  then  by  orderly 
drill  and  calisthenics.  In  this  way  spontaneity  becomes  con- 
trolled in  accordance  with  a  definite  purpose,  and  the  child 
learns  to  acquire  the  habits  of  obedience  and  attention.  This 
naturally  leads  up  to  still  more  regular  and  systematized  exercises, 
in  the  shape  of  such  kindergarten  occupations  as  building  with 
cubes,  stick-laying,  bead-threading,  pricking  outlines,  knotting 
and  looping,  paper  cutting  and  folding ;  and  these,  in  turn, 
are  superseded  by  clay-modelling,  •  macrame  work,  knitting 
and  darning,  and  finally  by  definite  technical  instruction  in 
wood-carving,  carpentry,  basket-weaving,  mat-making,  needle- 
work, laundry  work,  and  dressmaking,  etc.  Coincidently, 
speech  is  cultivated,  instruction  is  given  in  the  three  R's,  and 
every  care  is  taken  to  repress  injurious  propensities  and  to 
develop  moral  character. 

The  general  principles  of  education  do  not  differ  from  those 
in  the  case  of  the  mentally  normal,  the  difference  being  merely 
one  of  method  and  application.  The  whole  object  of  the 
teacher  is  to  reduce  the  environment  of  the  child  to  a  form 
which  the  deficiency  of  his  mind  is  capable  of  assimilating,  at  the 
same  time  taking  care  that  his  mental  pabulum  is  administered 
in  an  attractive  shape.  It  may  safely  be  said  that  no  success 
will  be  attained  unless  the  child's  interest  is  aroused,  and  this 
must  be  the  teacher's  first  care.  It  is  by  means  of  this  interest 
and  its  progressive  expansion,  by  gradually  leading  him  step 
by  step  from  one  acquirement  to  another,  that  the  capacity 
of  the  child  is  unfolded  and  that  his  education  is  accomplished. 
In  many  cases  even  destructive  tendencies,  where  the  child 
will  do  nothing  but  tear  into  pieces  everything  given  to  him, 
may  be  made  use  of  as  the  first  stepping-stone  to  manual  work. 
Above  all,  it  is  necessary  to  remember  that  these  children's 
conception  of  the  abstract  is  extremely  limited,  that  every- 
thing must  be  presented  in  the  concrete,  and  that  they  will 
learn  far  more  with  their  hands  than  with  their  heads. 

22 


338  Mental  Deficiency 

It  is  necessary  to  pay  particular  attention  to  the  cultivation 
lof  the  sensory  and  motor  functions.  In  the  ordinary  child  these 
iare  perfected  as  the  result  of  his  own  initiative,  but  in  the  ament 
special  stimulation  is  required — not  only  because  of  the  presence, 
in  a  considerable  proportion  of  these  children,  of  defects  and 
irregularities  of  nerve  action  (abnormal  nerve  signs),  which 
must  be  corrected  before  useful  manual  work  can  be  accom- 
plished, but  because  such  training  affords  a  most  valuable 
means  of  developing  and  co-ordinating  intellectual  activity. 
"^  Thus,  by  means  of  suitable  impressions_through  eye,  ear,  skin, 
muscle,  nose,  and  mouth,  the  range  and  delicacy  of  the  sensorium 
is  increased,  the  brainrendered  more  receptive,  the  power  oj 
discriminatioifr  as  well  asinotor  response^  encouraged,  and  a 
basis  supplied  for  future  thoughts  and  ideasT  We  liveT^  course, 
in  a  perfect  sea  of  sights,  sounds,  and  vibrations  of  every  kind, 
and,  as  already  remarked,  the  healthy  brain  is  so  constituted 
that  it  can  utilize  these  without  any  special  tutorial  help,  (l 
do  not  say  that  this  is  likely  to  lead  to  an  optimum  result  ;  in 
fact,  I  believe  that  the  mental  capacity  of  even  the  healthy 
child  would  be  greatly  improved  by  a  course  of  sensory  training 
on  physiological  line^.  It-  is  doubtful  whether  the  mental 
development  of  anyone,  even  the  best,  comes  up  to  the  inherent 
possibilities.  In  the  case  of  the  defective  mind,  however,  such  a 
course  of  training  is  usually  absolutely  necessary,  and  constitutes 
;    a  most  important  part  of  education. 

,       Similarly    with   regard   to    the    motor   system.     All_jnentaJ 
;   action  is  eyprfi<;c;prl  Y^y  movement,  or  ir^iHti«^T^  iTPmnvprnpnt^ 
j.^^of__some  kind  or  ^^h'^r      It  may  be  the  mere  opposition  of  the 
thumb  and  forefinger,  the  play  of  facial  expression,  the  com- 
plicated mechanism  of  speech,  or  the  deliberate  conformation 
of  the  whole  being  to  some  emotion  or  ideal,  as  seen  in  conduct 
and  behaviour.     Since  it  is  by  the  character  of  his  movements 
and  actions  and  general  behaviour  that  the  entire  relationship 
of  the  mentally  deficient  child  to  the  rest  of  society  will   be 
determined,  it  is  plain  that  the  development  of  the  motor  system 
is  of  the  greatest  importance.     We  may,  indeed,  say  that  all 
means  for  the  cultivation  of  mental  faculty  are  of  importance 
.  according   as   they   develop,   co-ordinate,    and   control   mental 
manifestations — i.e.,  movements. 


Treatment  and  Training  339 

Such,  then,  are  the  general  principles  upon  which  the  educa- 
tion of  the  mentally  deficient  child  must  be  based,  and  of  which 
some  further  details  will  be  given  presently.  It  is  obvious, 
however,  that,  although  we  must  be  guided  by  these  principles, 
the  measure  of  success  achievable  will  vary  enormously,  and 
will  be  dependent  upon  the  degree  of  initial  defect — or  perhaps 
I  should  rather  say  upon  the  inherent  capacity  for  development 
present  in  any  particular  case.  This  cannot  be  foretold  ;  but 
undoubtedly  there  is  a  limit,  and  a  point  is  at  last  reached 
beyond  which  no  further  advance  takes  place. 

In  the  idiots  we  shall  get  no  farthftrj-han  J±ie  implanting  of 
habits  of  cleanliness,  the  develo£ment_Qi_some  capacity  for  self- 
feeding  and  self-help,  the  curtailing  of  destructive  and  vicious 
propensities,  and  the  expression,  by  signs  or  words,  of  sim^^^g^^ 
wants.  And  we  may  not  get  even  so  far  as  this.  In  the 
imbeciles  a  higher  stage  will  be  attainable,  and  not  only  may 
they  be  made  to  be  much  more  self-helpful  and  less  dependent, 
but  they  may  even  be  taught  to  perform  a  certain  amount  of 
useful  routine  work.  Lastly,  in  the  case  of  the  feeble-minded 
the  result  achieved  may  he  very  considerable.  A  goodly  number 
will  become  orderly,  industrious,  and  well-behaved  individuals,  \}M^ 
perhaps  able  to  read  and  write  a  little,  to  do  simple  sums,  and  J"*' 
capable  of  performing  useful  work,  which  will  at  the  same  time! 
keep  them  happily  engaged  and,  where  necessary,  contribute/ 
to  their  support.     ^\  ^^^ye-  will  never  take  place. 

We  may  now  rei^  to  some  points  regarding  the  application 
of  these  principles  to  home  and  school  training. 

Home  Training. 

The  training  of  the  mentally  deficient  child  should  begin  \ 
at  birth,  or  as  soon  as  the  condition  is  diagnosed.  The  ament, 
even  more  than  the  normal  child,  rapidly  develops  bad  habits, 
and  care  in  the  early  years  of  life  may  not  only  do  much  to  prevent 
these,  but  will  be  of  the  greatest  assistance  in  paving  the  way 
for  the  more  systematic  training  of  after-years.  This  early 
training  must  of  necessity  be  carried  out  at  home,  and,  where 
circumstances  permit,  it  is  advisable  that  it  should  be  at  the 
hands  of  a  trained  governess  ;  but  where  this  is  not  possible 

22—2 


It  u. 


340  Mental  Deficiency 

it  must  be  undertaken  by  the  parents.  In  any  case,  the  growth 
and  well-being  of  the  child's  mind,  as  well  as  body,  should  be 
under  the  general  supervision  of  the  medical  attendant. 

I  have  already  emphasized  the  necessity  for  telling  the  parents 
the  truth  regarding  the  condition  of  their  child  ;  I  would  here 
remark  that  it  is  also  the  physician's  duty  to  state  plainly  that 
neglect  at  this  time  may  mean  the  development  of  habits  which 
it  may  take  years  to  eradicate,  whilst  care,  kindness,  and,  above 
all,  patience,  will  certainly  result  in  improvement.  Suitable 
food,  clothing,  warmth,  exercise,  fresh  air,  regular  bathing — in 
fact,  attention  to  all  concerning  the  general  bodily  health — are 
of  the  first  importance,  whilst  the  habit  of  cleanliness  cannot 
be  enforced  too  early.  Its  acquirement  in  all  but  the  most 
degraded  idiots  is  usually  only  a  matter  of  patience.  With  regard 
to  training,  there  is  no  need  for  anything  elaborate  ;  but  the 
practice  of  relegating  these  children  to  out-of-the-way  corners, 
and  of  depriving  them  of  those  adjuncts  to  development  which 
they  need  far  more  than  do  ordinary  children,  is  one  which 
cannot  be  too  strongly  condemned.  What  is  required  at  this 
time  is  a  little  more,  and  not  a  little  less,  care  and  patience. 
The  child  must  be  talked  to  and  encouraged  to  play.  If  destruc- 
tive, it  must  be  gently  but  firmly  repressed.  If  inactive,  its 
little  hands  must  be  made  to  feel  the  contact  of  toys,  its  sight 
stimulated  by  brightly  coloured  balls,  and  its  hearing  by  music, 
or  even  noise.  Instead  of  depriving  it  of  toys,  let  it  have  an 
abundance  to  see  and  handle,  and  even  to  break.  As  it  gets 
older,  encourage  it  to  sit  up,  to  stand,  and  to  walk,  and  do  all 
that  is  possible  to  develop  and  co-ordinate  sensory  and  motor 
activity.  If  the  child  is  to  be  rescued  from  its  solitary  position, 
the  time  so  spent  will  not  be  wasted. 

I  think  one  of  the  most  deplorable  things  in  connexion  with 
these  unfortunate  children  is  the  neglect  which  so  often  attaches 
to  their  early  home  life.  I  do  not  think  that  this  arises  from 
unkindness,  for  I  have  often  been  struck  by  the  manifest  solici- 
tude of  parents  and  all  those  about  them.  It  is  simply  a  matter 
of  sheer  ignorance  as  to  what  to  do  and  how  to  do  it,  but  it 
often  results  in  the  development  of  habits  which  are  ineradicable. 


Treatment  and  Training  341 


School  Training. 

Where  the  home  conditions  are  such  that  adequate  training 
cannot  be  obtained,  or  when  such  training  no  longer  suffices  for 
the  needs  of  the  child,  he  should  be  removed  to  a  special  training 
institution.  Usually  this  is  about  the  sixth  or  seventh  year,  but 
in  certain  circumstances  it  may  be  advantageous  to  remove  the 
child  earlier,  whilst  in  others  he  may  stay  at  home  until  a  later 
age  than  this.  The  milder  defectives — i.e.,  mentally  deficient 
children  who  are  not  imbeciles — come  within  the  operation  of  the 
Education  Act  at  seven  years,  and  may  then  be  compelled  to 
attend  special  classes  or  schools,  if  such  exist. 

School  training  consists  of  more  systematized  methods,  havingl 
for  their  object  the  development  of  the  sensory,  motor,  intel-\ 
lectual,  and  moral  faculties  of  the  child.     It  is  necessarily  less  ' 
individual  than  the  training  he  has,  or  should  have,  received  at 
home  ;  but  this  defect  is  more  than  compensated  for  by  the 
spirit  of  emulation  and  of  companionship  which  results  from 
association  with  other  children  like  himself.     Moreover,  although 
children  in  institutions  must  of  necessity  be  taught  in  classes,  it 
is  still  possible,  by  carefully  grading  and  seeing  that  such  classes 
are  not  too  large,  to  ensure  for  each  child  a  sufficient  amount  of 
individual  attention.     The  regulations  of  the  Board  of  Educa- 
tion require   at   least   one   teacher   to   every   twenty   defective 
children,  but  in  lower-grade  aments  the  proportion  of  children 
must  be  very  much  reduced. 

As  we  have  seen  in  previous  chapters,  aments,  with  regard  to 
the  type  of  their  nervous  constitution,  are  divisible  into  two  main 
groups.  On  the  one  hand  there  are  those  who  are  passive,  inert, 
and  markedly  deficient  in  spontaneity  ;  on  the  other  there  are 
those  who  are  restless  and  exceedingly  motile,  full  of  "  tricks," 
"  habits,"  and  impulsive  acts,  and  markedly  deficient  in  the 
power  of  sustained  attention.  In  each  of  these  the  training  is  in 
accordance  with  the  general  physiological  principles  which  have 
already  been  alluded  to — namely,  stimulation  through  the  sensory 
channels — but  the  method  is  different  in  the  two  classes.  The 
stolid  group,  whose  main  defect  is  one  of  excitability,  require 
stimulation   by  means   of  romping  games,   musical   drill,    and 


^:'A. 


342  Mental  Deficiency 

vigorous  impressions  of  all  kinds.  The  restless  and  excitable 
class,  on  the  other  hand,  require  their  excessive  movements  to 
be  brought  under  the  control  of  the  will  by  deliberate  and  syste- 
matic exercises,  such  as  are  comprised  in  many  of  the  kinder- 
garten occupations.  But  apart  from  these  broad  differences, 
mentally  deficient  children  differ  enormously  in  their  power  of 
response  as  well  as  in  the  presence  of  particular  defects  or  irregu- 
larities of  brain  function,  and  it  is  the  duty  of  the  physician  in 
charge  to  make  a  careful  examination  of  each  child,  and  to 
advise  the  teacher  regarding  the  appropriate  method  of  training. 
Individual  teaching  must  still  be  the  keynote,  and  the  teacher 
must  ever  be  on  his  guard  against  neglecting  the  laggards  for 
the  sake  of  those  of  more  promise. 

Teaching  is  an  art  which  cannot  be  taught.  It  must  come  by 
practical  experience  of  the  management  of  children.  The  fol- 
lowing brief  account  simply  aims  at  suggesting  some  of  the  chief 
physiological  methods  upon  which  training  should  proceed.  The 
teacher  with  a  love  for  his  work  and  his  pupils  will  have  no 
difficulty  in  adapting,  modifying,  or  extending  these  to  suit  the 
needs  of  any  particular  child,  always  bearing  in  mind  that  the 
chief  requirements  are  the  development  of  what  is  defective  and 
the  elimination  of  v(^hat  is  faulty. 

The  Training  of  the  Senses. — The  chief  sensory  organs  through 
which  impressions  reach  the  brain  are  six  in  number — namely, 
eye,  ear,  nose,  mouth,  skin,  and  muscle.  Probably  the  training 
of  the  first  and  last  of  these  are  of  most  importance. 

By  means  of  vision,  information  is  gained  regarding  the  colour, 
size,  and  form  of  objects,  and  attention  should  be  given  to  each 
of  these.  It  will  often  be  found  that,  whilst  the  high-grade  ament 
distinguishes  the  primary  colours  readily  enough,  he  is  unable  to 
separate  their  shades  ;  and  that,  whilst  he  distinguishes  between 
the  form  of  a  triangle,  a  square,  and  a  circle,  he  fails  to  see  any 
difference  between  triangular  or  quadrangular  figures  of  varying 
shape. 

For  teaching  colour  discrimination,  a  very  convenient  apparatus 
is  a  series  of  cardboard  tables,  each  i  inch  square,  and  of 
a  different  shade.  We  may  have  six  or  eight  shades  of  each 
of  the  colours  blue,  red,  green,  yellow,  orange,  and  purple.  It 
is   unnecessary    that    the    child    should    know   the    names,  all 


Treatment  and  Training  343 

that  he  is  wanted  to  do  being  to  separate  the  collection  of 
tablets  into  heaps  according  to  their  shade.  Subsequently  he 
may  be  taught  their  names.  Coloured  beads  or  wools  may  be 
made  use  of  in  the  same  way,  and  as  the  child  progresses  he  will 
find  great  delight  in  pointing  out  to  the  teachers  the  different 
colours  in  pictures  which  are  shown  to  him.  Later  on  the 
kaleidoscope  may  be  turned  to  profitable  account  in  the  develop- 
ment of  colour  discrimination. 

For  cultivating  the  child's  perception  of  form  and  size,  it  is . 
first  of  all  necessary  to  draw  his  attention  to  the  coarse  differ- 
ences in  the  many  objects  of  common  use.  After  this  we  may  ' 
make  use  of  a  similar  series  of  tablets  of  various  sizes  and  shapes, 
but  of  uniform  colour,  again  getting  him  to  divide  them  into 
heaps.  *'  Size,"  "  form,"  and  "  peg  "  boards,  as  well  as  the 
ordinary  dissected  puzzles  of  the  toy-shops,  not  only  afford 
valuable  visual  training,  but  are  also  of  great  use  in  developing 
tactile  sense  and  in  aiding  muscular  co-ordination. 

The  cultivation  of  the  tactile  and  muscle  senses  is  particularly  J^cacM 
called  for  in  the  case  of  mentally  deficient  children,  since,  in  addi-^  ^  , 
tion  to  its  general  educational  value,  these  are  functions  which 
are  absolutely  essential  for  the  proper  performance  of  manual 
occupations,  and  the  future  of  the  ament  must  depend  to  a  very 
great  extent  upon  how  he  can  use  his  hands. 

Sensations  travel  to  the  brain  from  the  muscles  just  the  same 
as  from  eye,  ear,  nose,  etc.,  and  with  a  little  practice  they  may  ' 
be  appreciated  and  compared  with  one  another  in  precisely  the 
same  way.  These  sensations  arise  in  two  ways:  First,  when  a 
muscle  or  series  of  muscles  is  moved  ;  secondly,  during  the  tension 
of  a  muscle.  Generally  speaking,  impressions  arising  during 
muscular  contraction  are  of  use  in  appreciating  size  and  distance, 
whilst  those  coming  from  muscular  tension  tell  us  of  weight. 
Of  course,  in  the  actions  of  ordinary  life  we  make  use  of  several 
senses  simultaneously,  and  those  from  muscle  are  aided  by  others 
from  skin  and  eye.  In  training,  however,  it  will  usually  be 
found  advantageous  for  the  pupil's  eyes  to  be  kept  closed  during 
these  exercises. 

In  the  inert,  unresponsive  type  of  aments,  we  may  have  to 
stimulate  the  sensorium  by  passive  movements  of  the  limbs,  or  by 
compelling  the  hands  to  grasp,  to  feel,  and  to  let  go  objects  of 


344  Mental  Deficiency 

different  texture,  temperature,  density,  and  coarseness  or  smooth- 
ness of  surface.  In  the  restless  and  abnormally  motile  type,  con- 
■  trol,  co-ordination,  and  attention  will  be  improved  by  blindfolding 
the  child,  and  getting  him  to  differentiate  between  form  and  size 
tablets  by  passing  his  fingers  round  their  edge.  Many  mild 
imbeciles  will  enter  with  zest  into  the  game  of  guessing  articles 
in  a  bag  by  simply  feeling  them.  Another  excellent  method  is 
that  recommended  by  Dr.  Warner.  It  consists  in  accustoming 
the  child  to  differentiate  between  varying  weights  of  shot  con- 
tained in  a  small  chip-box  held  upon  the  extended  palm.  Miss 
Mumbray,  who  has  had  a  large  practical  experience  of  the 
training  of  mentally  defective  children,  is  in  the  habit  of 
directing  her  pupils  to  measure  off  on  a  sheet  of  paper  a 
series  of  prescribed  distances — say  from  J  inch  to  4  or  6  inches. 
After  a  little  practice  at  this  they  are  required  to  draw  lines 
of  specified  length  without  the  measure.  In  this  exercise  the 
ocular  as  well  as  the  finger  movements  are  utilized,  and  the 
results  are  not  only  extremely  good  in  themselves,  but  are  of 
the  greatest  value  in  leading  up  to  kindergarten  occupations. 
Sloyd,  and  subsequently  industrial  training. 

It  occasionally  happens  that,  instead  of  sensation  being  dimin- 
ished, it  is  so  much  increased  as  to  become  a  source  of  pain.  The 
hypersesthetic  hands  must  then  be  em.ployed  in  rough,  coarse 
work  until  their  sensibility  is  dulled. 

Hearing  is  often  defective  in  aments,  but  many  of  these  children 
are  thought  to  be  deaf  when  the  real  deficiency  is  one  of  spon- 
taneous attention.  The  besit  means  of  developing  this  faculty 
is  by  music.  Singing,  musical  drill,  and  the  concerts  of  the 
entertainment-hall,  which  should  form  part  of  the  life  of  all 
institutions,  not  only  develop  the  child's  power  of  attention  and 
the  range  and  accuracy  of  his  hearing,  but  are  a  source  of  the 
greatest  happiness. 

(Where  the  senses  of  taste  and  smell  are  in  need  of  special  culti- 
vation, this  may  be  accomplished  by  placing  upon  the  tongue  such 
substances  as  sugar,  quinine,  salt,  chlorate  of  potash,  soda,  etc.,  or 
by  getting  him  to  sniff  coffee,  cocoa,  snuff,  or  various  essential  oils) 
The  Training  of  Movement. — It  is  impossible  to  overrate  the 
importance  of  this.  The  mentally  deficient  child  who  has  been 
taught  to  walk,  to  speak,  and  to  dress  and  feed  himself,  has 


Treatment  and  Training  345 

obviously  been  materiallj^  benefited — still  more  so  is  this  the  case, 
however,  when  patient  and  systematic  training  has  enabled  him 
to  put  his  hands  to  some  useful  occupation.  But  a  higher  result 
even  has  been  achieved.  Mental  action  and  motor^activitv  go 
hand-in-hand,  and  in  the  development  of  muscular  co-ordination_ 
ties'oneof  our  best  means  of  cultivating  self-control  and  regularity 
6t  mental  action." 

The  training  of  movement  in  the  mentally  deficient  resolves 
itself  into  three  processes  :  (i)  the  development  of  action,  (2)  its 
co-ordination,  (3)  the  correction  of  motor  anomalies  in  the  form 
of  tricks  and  habits.  These  two  latter  are  accomplished  by  the 
same  means.  Speech  is  also  a  motor  phenomenon,  but  it  will 
be  convenient  to  refer  to  it  separately. 

The  Development  of  Movement. — As  we  have  seen,  a  propor- 
tion of  aments  are  listless,  torpid,  and  inactive.  They  are  quite 
content  to  sit  still  and  do  nothing,  and  they  even  evince  no 
interest  in  the  games  of  their  companions.  This  condition  is 
usually  the  result  of  a  general  sluggishness  of  the  nervous  system, 
but  it  is  occasionally  caused  by  nervous  exhaustion  due  to  ill- 
health.  In  the  latter,  rest,  food,  and  fresh  air  are  necessary ;  in 
the  former,  active  and  vigorous  stimulation  is  required. 

The  only  means  of  stimulating  the  motor  cells  of  such  a  child 
is  through  the  sensory  pathways,  and  these  we  must  endeavour 
to  excite  by  every  possible  device.  The  child  must  be  talked  to ; 
his  attention  must  be  attracted  by  brightly  coloured  objects  ; 
he  may  be  bombarded  with  small  flannel  bags  filled  with  beans, 
until  he  holds  up  his  hands  to  protect  himself,  and  eventually 
assumes  the  offensive ;  he  must  be  made  to  listen  to  and  join 
in  the  romping,  singing  and  drilling  of  the  class ;  by  any  means 
he  must  be  made  to  move,  and  until  this  has  been  accomplished 
systematic  lessons  are  quite  out  of  place. 

The  Co-ordination  of  Movement. — With  the  development  of 
movement,  its  co-ordination  must  be  attended  to.  In  the  healthy 
child  this  takes  place  naturally  through  the  constant  repeti- 
tion induced  by  its  own  initiative.  *'  Practice  makes  perfect." 
In  the  ament  the  nervous  discharge  is  irregular,  and  the 
harmonious  adaptation  of  the  motor  response  to  the  sensory 
stimuli,  so  that  an  optimum  result  follows  a  minimum  expendi- 
ture, is  slowly  and  laboriously  acquired. 


346  Mental  Deficiency 

Co-ordination  is  more  readily  developed  in  the  case  of  a  few 
large  muscles,  such  as  those  concerned  in  standing,  walking,  and 
pushing,  than  in  the  twenty  odd  small  muscles  of  the  hand  or  in 
the  intricate  muscular  apparatus  concerned  in  speech.  Conse- 
quently, the  first  exercises  must  be  directed  towards  teaching  the 
child  to  maintain  a  proper  balance  of  the  body,  to  run  and  to 
walk,  to  push  and  pull,  to  seize,  to  hold,  and  to  let  go,  tolerably 
large  objects.  For  this  purpose  such  exercises  as  mounting  a 
ladder  placed  against  a  wall,  walking  between  the  rungs  of  a 
ladder  placed  fiat  upon  the  ground,  marching  in,  out,  and  over 
various  obstacles  to  the  accompaniment  of  music,  and  accurately 
covering  with  the  feet  a  series  of  footprints  chalked  upon  the 
ground,  as  recommended  by  Seguin,  are  of  the  highest  service. 

At  a  later  stage  finer  movements  of  the  trunk  and  limbs  may 
be  attended  to,  and  here  games  with  a  ball  (such  as  cricket,  foot- 
ball, and  rounders),  free  exercises,  musical  drill,  dumb-bells,  and 
breathing  exercises,  find  their  place.  The  daily  occupations  of 
dressing  and  feeding,  particularly  the  management  of  the  spoon, 
afford  most  valuable  fields  of  instruction.  In  milder  cases, 
definite  **  eye-drill  "  may  be  given. 

Lastly,  manual  dexterity  must  be  developed  by  the  kinder- 
garten occupations,  writing,  drawing,  cutting-out,  paper-folding, 
clay-modelling,  and  the  like.  The  imitation  and  transfer  move- 
ments of  Warner  may  here  be  utilized  in  some  of  the  mildest 
cases.*  Dr.  Warner,  in  fact,  regards  them  as  "  far  more  educa- 
tive than  clay-modelling,  drawing,  and  other  child  occupations." 
Theoretically  this  is  so,  but  it  is  possible  for  an  educational 
method,  as  for  an  article  of  food,  to  be  so  concentrated  as  to  be 
inappetizing  ;  and  these  exercises  have  the  disadvantage  of  being 
somewhat  uninteresting,  and  of  requiring  an  amount  of  atten- 
tion of  which  the  mentally  defective  child  is  often  incapable, 
hijthe  training  of  these  children  interest  is  everything. 

The  correction  of  irregular  movements  in  the  form  of  athetosis, 
"  tricks,"  or  "  habits,"  is  accomplished  by  the  same  methods  as 
those  used  to  develop  co-ordination.  Where  the  abnormality  is 
chiefly  in  the  hands,  the  kindergarten  occupations,  or  in  coarser 

*  See  an  interesting  paper  by  Dr.  Warner  on  "  The  Training  of  the 
Intelligence  through  the  Hand,"  read  at  the  annual  meeting  of  the  Sloyd 
Association,  1902. 


Treatment  and  Training  347 

cases  the  peg-board,  will  be  found  of  great  service.  This  latter 
is  a  flat  rectangular  board  drilled  with  holes  of  varying  size,  into 
which  corresponding  pegs  are  to  be  fitted.  Where  the  motor 
irregularity  concerns  the  face  or  trunk,  facial  and  bodily  gym- 
nastics are  indicated. 

The  Training  of  the  Intelligence. — No  means  exist,  or  ever  will 
exist,  by  which  we  can  supply  intelligence  to  the  mentally  defi- 
cient. Each  of  these  children  has  a  certain  capacity  for  develop- 
ment, which  it  is  the  object  of  training  to  educate,  or  "  lead  out," 
and  which  in  the  absence  of  appropriate  training  would  remain 
undeveloped.  To  a  very  considerable  extent  this  is  accom- 
plished, as  already  remarked,  by  systematic  exercises  stimulating 
the  receptive  and  perceptive  faculties,  and  developing,  controlling, 
and  correcting  the  motor  response.  In  the  present  section  I  pro- 
pose briefly  to  refer  to  some  of  the  principles  underlying  more 
direct  appeals  to  the  intelligence,  and  here  we  shall  also  con- 
sider reading,  writing,  and  speech.  These  methods,  of  course, 
are  only  applicable  to  the  milder  degrees  of  mental  deficiency. 

One  of  the  commonest  and  most  important  defects  occurring 
in  these  children  concerns  the  faculty  of  attention.  In  children 
of  the  inert,  placid  type,  spontaneous  attention  is  often  lacking, 
and  the  child  remains  unmoved  and  indifferent,  whatever  happens. 
This  condition  results  from  a  diminished  nervous  excitability, 
and  it  is  remedied  by  a  vigorous  bombardment  of  the  sensorium 
through  every  afferent  pathway.  "  On  the  other  hand,  the  rest- 
less, unduly  motile,  hyperexcitable  type  are  usually  characterized 
by  a  want  of  voluntary  attention  and  concentration.  Though 
seemingly  so  vivacious,  they  can  settle  down  to  nothing,  and 
almost  every  conscious  sensation  or  every  thought  distracts 
them  from  their  task.  The  only  way  in  which  concentration 
and  useful  work  can  here  be  obtained  is  by  presenting  the  child 
with  something  which  is  interesting.  In  fact,  the  keynote  to 
attention  is  interest,  and  the  psychological  principles  for  develop- 
ing the  power  of  attention  may  be  expressed  in  the  following 
three  maxims  :  First,  the  pupil's  occupations  must  be  those  in 
which  he  has  an  interest  naturally  (and  it  may  be  remarked  that 
the  child  whom  nothing  will  attract  is  in  a  very  parlous  state)  ; 
secondly,  his  interest  must  be  enlarged  by  the  introduction  of 
new  occupations  closely  allied  to,  and  leading  out  of,  those  in 


348  Mental  Deficiency 


which  he  is  naturally  interested  ;  thirdly,  an  artificial  or  derived 
interest  must  be  created  for  those  subjects  which  are  not  attrac- 
tive in  themselves,  or,  as  Ribot  says,  they  must  be  "  rendered 
attractive  by  artifice."  Rewards  of  various  kinds  form  useful 
attractions. 

The  process  of  association  is  of  paramount  importance  in 
mental  action.  By  its  means  all  the  varying  impressions  received 
through  the  senses  are  again  connected,  so  as  to  produce  a  com- 
plex picture  or  a  sequence  of  ideas.  Defective  power  of  associa- 
tion means  not  only  crudeness  of  the  individual  mental  images, 
but  often  paucity  of  images  and  ideas  generally.  In  training  this 
function,  the  method  is  the  opposite  of  that  employed  in  teaching 
discrimination.  There  sensations  were  presented  singly,  here 
they  are  presented  simultaneously ;  the  law  of  association  being 
that  impressions  which  are  simultaneously  received  by  the  brain 
tend  to  acquire  functional  connexions.  For  example,  let  the 
child  handle,  bite,  note  the  form  and  colour  and  learn  the  name 
of,  a  shilling.  The  subsequent  auditory  sensation  "shilling" 
will  call  up  a  mental  picture  composed  of  its  associates.  Object- 
lessons  are  also  of  great  value  in  training  association. 

Memory  is  largely  dependent  upon  the  power  of  association, 
and  in  proportion  as  we  develop  this  so  we  cultivate  memory. 
It  is  very  useful  to  encourage  the  child's  power  of  recall  by  getting 
him  to  give  an  account  of  the  things  seen  or  done  upon  returning 
from  a  walk  or  at  the  end  of  the  day.  Exercises  in  repeating 
poetry,  quotations,  and  the  like,  help  the  child  to  remember  the 
particular  things  repeated,  but  it  is -a  mistake  to  imagine  that 
they  do  anything  towards  cultivating  the  "  faculty"  of  memory 
in  general. 

The  capacity  for  forming  thoughts,  judging  and  reasoning,  is 
best  stimulated  and  encouraged  by  individual  contact  with 
that  teacher  who  knows  how  to  present  to  the  deficient  mind  in 
an  easily  assimilable  form  the  simple  facts  of  nature  and  every- 
day life.  What  are  called  object-lessons  are  here  of  the  greatest 
value,  but  their  value  consists,  not  so  much  in  the  matter,  as  the 
manner  in  which  they  are  presented.  A  good  teacher  will  know 
how  to  turn  almost  anything  to  account,  although  most  benefit 
will  result  from  those  objects  in  which  the  child  has  a  natural 
interest.     It  is  of  the  highest  importance  that  he  should  be  care- 


Treatment  and  Training  349 

fully  questioned  and  encouraged  to  ask  questions,  and  the 
teacher  must  ensure  that  everything  is  in  the  concrete,  and  that 
the  ideas  presented  to  the  child  have  their  visible,  tangible,  and 
material  counterparts. 

Speech. — The  mechanism  concerned  in  speech,  and  the  chief 
anomalies  present  in  the  mentally  deficient,  have  been  described 
in  a  previous  chapter.  In  some  of  these  children  speech  is 
absent  in  consequence  of  a  lesion  of  the  motor  centre,  and  these 
cases  are  probably  incurable.  In  others  intractable  deafness  is 
the  cause,  and  then  occasionally  (but  very  occasionally  where 
mental  defect  is  present),  speech  may  be  acquired  by  means  of 
lip  imitation.  Other  children  of  the  lower  grades  apparently 
never  speak  because  they  have  no  ideas  to  express,  or  because 
it  is  easier  for  them  to  voice  their  feelings  by  grunts,  screeches, 
and  inarticulate  noises.  In  the  majority  of  the  milder  aments, 
however,  there  is  some  ability  to  speak,  but  speech  is  faulty  and 
imperfect  in  consequence  of  conditions  which,  if  not  entirely 
curable,  are  at  least  in  great  part  ameliorable  by  treatment. 

There  are  two  chief  causes  of  these  defects  :  First,  anatomical 
abnormalities  of  the  end-organs  concerned  in  speech-production 
or  in  the  perception  of  sounds ;  secondly,  deficient  muscular 
action  and  inco-ordination.  The  former  of  these  consist  of 
adenoids,  enlarged  tonsils,  cleft  palate,  suppurating  otitis,  etc., 
and  are  chiefly  responsible  for  thickness,  indistinctness,  and 
alterations  of  tone.  These  must  be  attended  to  by  the  surgeon 
before  systematic  instruction  is  attempted.  Muscular  inco- 
ordination gives  rise  to  stammering,  stuttering,  inability  to 
pronounce  certain  consonants,  and  the  habit  of  substituting  easy 
sounds  for  those  which  are  difficult.  The  essence  of  speech 
training  consists  in  discovering  the  nature  and  cause  of  the 
particular  faults,  and  remedying  them  by  the  appropriate 
methods. 

Where  muscular  action  is  defective,  which  may  be  but  part  of 
a  general  inertia  as  seen  in  the  stolid  type  of  aments,  it  may  be 
cultivated  by  encouraging  the  child  to  make  use  of  his  lips  and 
tongue  in  blowing  a  toy  trumpet  or  whistle.  But  in  cases  where 
muscular  inco-ordination  is  the  chief  fault  this  is  unnecessary, 
although  such  children,  including  stutterers  and  stammerers, 
will  be  benefited  by  a  course  of  lip  and  tongue  gjTnnastics  and 


350  Mental   Deficiency 

breathing  exercises.  In  many  cases  where  the  faculty  of  speech 
Hngers  music  is  a  great  help.  As  Dr.  Shuttle  worth  says, 
"  Such  children  will  frequently  hum  tunes  that  take  their  fancy 
before  they  are  able  to  articulate  words  ;  but  if  attractive  tunes 
set  to  words  containing  repetitions  of  simple  sounds  (such  as  the 
*  Ba-ba,  black  sheep/  of  our  old  nursery  rhymes)  are  constantly 
repeated  to  them,  the  probability  is  that,  after  a  time,  first  one 
word  and  then  another  will  be  taken  up  by  the  pupil,  till  the 
rhyme  as  well  as  the  tune  is  known." 

In  cases  of  slurring,  word-clipping,  and  consonantal  defects, 
the  fault  generally  lies  in  a  want  of  synergic  action,  and  the 
only  remedy  is  for  the  teacher  to  demonstrate  with  his  own 
articulatory  apparatus  how  the  defective  sound  should  be  pro- 
duced, until  the  child  is  able  to  imitate  it.  This  requires  con- 
siderable patience  of  both  teacher  and  pupil,  and  it  is  essential 
that  the  latter  should  carefully  watch  the  teacher's  mouth  and 
hps  the  while.  It  is  useful  to  remember  that  many  consonants 
which  cannot  be  pronounced  at  the  beginning  of  a  word  can  be 
produced  in  the  middle,  and  thus  the  desired  sound  may  often  be 
forthcoming  if  it  is  preceded  by  one  the  child  knows. 

Writing  naturally  follows  speech,  and  the  first  steps  consist 
in  the  making  of  strokes  upon  the  ruled  slate.  Much  of  the  diffi- 
culty experienced  by  defective  children  is  the  result  of  imperfect 
co-ordination,  which  only  practice  and  patience  will  overcome, 
and  many  of  the  imbeciles  never  do  overcome  it.  In  any  case 
it*will  be  necessary  for  the  teach-er  to  guide  the  child's  hand  in 
his  initial  attempts  at  making  vertical,  horizontal,  and  oblique 
lines,  and  this  may  have  to  be  kept  up  for  weeks.  Some  children 
learn  to  make  rough  drawings  more  easily  than  to  write,  probably 
because  the  task  is  more  interesting,  and  the  practice  of  tracing 
pictures  which  underlie  a  piece  of"framed  frosted  glass  is  some- 
times of  assistance  to  writing.  The  imbecile  who,  after  repeated 
coaxing,  is  unable  to  make  any  attempt  at  tracing,  and  whose 
only  result  is  a  meaningless  scribble,  is  probably  incapable  of 
being  taught. 

Reading. — Few  imbeciles  acquire  the  power  of  reading,  but 
the  majority  of  the  feeble-minded,  as  a  result  of  years  of  training, 
learn  to  read  books  of  simple  words  and  short  sentences.  Many 
of  the  higher  types,  indeed,  become  good  readers.     Probably 


Treatment  and  Training  351 

the  best  method  of  teaching  is  the  word  method,  in  which  short 
words  are  read  "  at  sight  "  before  any  attempt  is  made  to  teach 
the  alphabet  ;  but  time  and  patience  rather  than  any  particular 
method  are  the  chief  essentials. 

Arithmetic. — Number  is  usually  a  great  stumbling-block  to 
aments,  although  there  are  some  feeble-minded  persons  who 
have  an  extraordinary  affection  for  dates,  and  occasionally  ability 
to  calculate.  The  reason  of  their  difficulty  seems  to  be  their 
inability  to  appreciate  the  abstract,  and  it  is  essential,  in  teaching 
number,  that  concrete  examples  should  always  be  made  use  of. 
This  is  done  by  means  of  beads,  counters,  the  abacus,  or  by 
graduated  wooden  rods.  The  cultivation  of  the  child's  faculty  of 
discriminating  size  and  weight  through  his  muscle  sense,  in  the 
manner  previously  described,  is  a  useful  prelude  to  teaching 
him  number.  An  excellent  form  of  concrete  instruction  is 
afforded  by  the  '*  shop  lesson."  Having  mastered  the  principles 
of  addition  and  subtraction  by  means  of  actual  objects,  the  less 
defective  pupils  may  be  initiated  into  the  mystery  of  the 
numerical  symbols,  but  progress  with  these  will  usually  be  very 
laborious. 

Industrial  Training. 

Hitherto  we  have  been  concerned  with  the  chief  means  by 
which  the  intellectual  and  nervous  functions  of  the  mentally 
deficient  child  may  be  stimulated  and  brought  into  orderly  use — 
with  education  in  its  general  sense.  We  now  pass  to  technieal 
instruction.  It  is  not  to  be  assumed,  however,  that  the  two  are 
really  separate,  or  that  this  latter  has  no  educational  value.  On 
the  contrary,  technical  or  industrial  training  is  not  only  a  con- 
tinuation, and  the  natural  outcome,  of  many  occupations  and 
exercises  which  have  formed  part  of  the  general  training  ;  but 
in  itself  it  is  of  distinct  educational  value.  It  is  a  well-recognized 
fact  that  the  mentally  deficient  child  learns  more  with  his  hands 
than  with  his  head  ;  whilst  his  future  is  far  more  a  matter  of 
manual  than  of  mental  dexterity.  Industrial  and  technical 
training,  therefore,  is  at  once  an  educational  factor  of  consider- 
able importance,  as  well  as  the  only  means  of  turning  these 
unfortunate  children  to  practical  account.  It  has  been  shown 
that,  as  a  result  of  this  training,  a  considerable  number  of  the 


352  Mental  Deficiency 

milder  aments  become  capable  of  remunerative  work  ;  and  even 
where  the  social  position  is  such  that  this  is  unnecessary,  it  is 
still  of  the  greatest  use  in  providing  them  with  employment. 
The  teaching  of  a  definite  occupation,  then,  should  never  be 
omitted,  and  should,  if  possible,  be  begun  during  childhood  or 
adolescence.  One  cannot  but  feel  that  in  many  instances  there 
is  a  tendency  to  allow  school-training  to  go  beyond  its  real 
purpose — that  of  cultivating  intellectual  and  nervous  action 
generally — and  to  make  it  too  scholastic. 

The  nature  of  the  industrial  training  must  be  determined  by 
the  particular  characteristics  of  the  individual,  regard  being  paid, 
of  course,  to  sex  and  social  position,  and  to  the  probable  environ- 
ment in  after-life.  Where  possible,  an  outdoor  occupation  should 
be  selected,  and  particularly  so  in  the  case  of  those  whose  coarsely 
formed  hands  stand  in  the  way  of  any  manual  dexterity — such, 
for  instance,  as  the  Mongolians.  But  care  must  be  taken  to 
protect  those  so  engaged  against  the  inclemency  of  the  weather, 
and  it  must  be  remembered  that  there  may  be  many  days  when 
this  will  absolutely  prevent  outdoor  work.  Gardening,  whether  of 
flowers,  fruit,  or  market  produce,  is  particularly  suitable,  and 
the  child's  taste  for  this  may  be  developed,  as  well  as  a  certain 
amount  of  useful  information  imparted,  by  practical  object- 
lessons  in  growing  seeds,  plants,  etc.,  in  the  schoolroom.  The 
strong  and  sturdy  type  may  be  usefully  employed  in  the  dairy 
or  on  the  farm. 

Where  regular  outdoor  work  is  impossible,  either  on  account  of 
the  physical  condition  of  the  patient  or  for  lack  of  accommodation, 
there  are  many  useful  and  remunerative  indoor  occupations  which 
may  be  taught.  Amongst  these  may  be  mentioned,  for  males, 
boot-making,  tailoring,  carpentry,  basket-weaving,  mat  and  brush 
making,  chair-caning,  book-binding,  and  such-like.  For  females 
there  are  cookery,  laundry  work,  dressmaking,  hand  and  machine 
sewing,  knitting,  and  even  embroidery  and  iine-art  needlework. 
In  all  well-equipped  institutions  a  considerable  amount  of  the 
making,  mending,  and  general  domestic  work  of  the  establish- 
ment— even  the  printing — is  performed  by  the  inmates,  under 
supervision.  Instruction  in  these  various  occupations  is,  of 
course,  given  by  skilled  master  hands. 


Treatment  and  Training  353 


Moral  Training. 

The  training  of  the  child's  moral  or  ethical  sense  is  by  no 
means  the  least  important  of  the  teacher's  duties  ;  indeed,  if  this 
is  not  carefully  attended  to,  the  education  of  his  intellect  may 
simply  result  in  an  increased  power  for  ill,  and  cause  him  to  be, 
not  merely  useless,  but  actually  dangerous  to  society.  Moral 
education,  therefore,  forms  an  essential  part  of  the  home  and 
school  training  of  the  mentally  deficient  child.  It  has  for  its  1 
general  object  the  repression  of  antisocial  tendencies  and  the  j 
inculcation  of  habits  or  principles  which  will  enable  the  child  to  \ 
adapt  his  conduct  to  the  laws  of  his  society  and  the  well-being 
of  his  fellow-creatures.  It  is  entirely  removed  from,  and,  from 
the  physician's  standpoint,  is  of  greater  importance  than,  religious 
education.  If  the  condition  of  the  child  permits,  the  elementary 
principles  of  a  religious  doctrine  may  be  added,  and  in  some  cases 
Christian  ideals  may  exert  a  considerable  effect  upon  the  moral 
behaviour.  The  question  of  religious  education,  however,  is  the 
domain  of  the  ecclesiastic,  and  beyond  the  scope  of  this  work. 

The  bulk  of  aments  are  rather  amoral  than  immoral,  and  their 
defect  of  ethical  sense  stands  in  the  same  relationship  to  that  of 
tile  normal  child  as  does  their  defect  of  general  intelligence, 
requiring  also  special  means  for  its  development.  There  are, 
however,  three  types  specially  prone  to  the  commission  of 
immoral  acts,  and  the  training  of  these  must  be  the  object  of 
particular  care. 

These  are,  first,  those  who  are  readily  induced  to  commit 
antisocial  acts,  at  the  instigation  of  unscrupulous  persons, 
because  of  their  extremely  "  facile  "  disposition.  Impression- 
able, susceptible,  and  readily  swayed,  utterly  incapable  of  with- 
standing the  suggestions,  good  or  bad,  of  their  companions,  the 
only  safeguard  is  to  keep  them  away  from  temptation,  and  to 
ensure  that  their  social  atmosphere  shall  be  good.  It  is  possible 
that  in  course  of  time  this  atmosphere  may  to  some  extent  lead 
to  the  formation  of  an  active  moral  sense,  and  that  the  persistent 
inculcation  of  moral  precepts  may  make  impressions  capable  of 
influencing  their  conduct  ;  but,  in  my  opinion,  this  can  never  be 
relied  upon,  and  the  only  safe  course  with  regard  to  this  class  is 

23 


oj 


354  Mental  Deficiency 

to  keep  them  under  permanent  supervision.  They  are  simple 
and  confiding  beings,  and  many  of  them  are  industrious  workers. 

The  second  group  consists  of  those  persons  whose  nervous 
constitution  is  so  unstable  and  explosive  that  the  most  trifling 
occurrence  serves  to  produce  a  violent  storm.  In  this  they  will 
Commit  a  grave  breach  of  discipline,  an  offence  against  law  and 
society,  or  even  a  serious  crime.  The  attacks  in  many  ways 
resemble  the  motor  storms  of  the  epileptic  ;  in  fact,  the  condi- 
tion may  well  be  termed  one  of  psychic  epilepsy.  In  such  cases 
some  degree  of  control  is  frequently  acquired  as  the  result  of 
regular  occupation,  careful  supervision,  and  firm  discipline. 
Medicinal  treatment  in  the  form  of  the  bromides  is  often  also  a 
valuable  adjunct,  and  by  these  means  considerable  improvement, 
or  even  cure,  may  be  brought  about. 

The -third  group  consists  of  the  so-called  moral  imbeciles.  In 
^,  these  there  seems  to  be  an  absolutely  ineradicable  propensity  to 
the  commission  of  every  kind  of  offence,  and  these  persons  will 
lie,  steal,  burn,  destroy,  and  assault,  without  being  influenced  in 
the  shghtest  by  persuasion,  threat,  or  punishment  of  any  descrip- 
tion. Again  and  again  have  I  known  the  offence  repeated  almost 
whilst  the  words  of  contrition  were  hot  upon  the  tongue.  I 
believe  that  this  condition  is  practically  incurable,  and  that  the 
only  safeguard  lies  in  strict  and  permanent  detention. 

Passing  now  to  the  ordinary  type,  in  which  there  is  neither  a 
specially  facile  disposition,  a  predisposition  to  emotional  storms, 
nor  deeply  ingrained  immoral  and  criminal  tendencies,  we  have 
to  consider  the  manner  in  which  the  latent  ethical  sense  may  be 
sufficiently  developed  to  lead  the  child  to  shape  his  conduct  in 
accordance  with  the  manners  and  customs  of  good  society.  If 
this  be  not  so  developed,  it  is  tolerably  certain  that  the  age  of 
puberty,  if  not  earher,  will  see  the  assertion  of  many  animal 
instincts  which  the  weakened  capacity  of  control  will  be  power- 
less to  overcoipe. 

It  was  stated  by  John  Stuart  Mill  that  the  foundation  of  the 
moral  principle  lies  in  utility.  The  mentally  normal  child  may 
be  taught  to  be  moral  through  a  gradual  recognition  of  this.  By 
being  made  to  suffer  the  natural  consequences  of  his  own  breaches 
of  discipline,  he  is  gradually  brought,  through  his  intellect,  to 
appreciate  that  virtue  is  attended  with  pleasurable,  and  vice  and 


Treatment  and  Training  355 

wrongdoing  with  unpleasant,  consequences.  To  a  certain  extent 
this  may  be  made  use  of  in  the  mentally  deficient  child,  but  his 
defect  is  often  such  that  he  cannot  be  made  to  appreciate  the 
natural  consequences,  the  utility  or  futility,  of  every  act  he  com- 
mits, and  this  result  can  only  be  attained  by  a  system  of  arbitrary 
rewards  and  punishments. 

There  are  many  rewards  for  good  conduct  which  appeal  to 
these  children.  In  the  lower  types  the  promise  of  a  toy,  a  sweet- 
meat, or  some  little  treat  in  the  shape  of  an  entertainment,  will 
often  prove  a  useful  incentive  to  good  behaviour.  Many  mentally 
defective  school-children  attach  great  value  to  the  little  card- 
board medal  pinned  upon  their  breast  by  the  teacher,  and  at  a 
later  stage  the  commendation  alone  of  the  instructor  to  whom 
they  have  grown  attached  will  suffice.  Similarly  with  punish- 
ment. The  deprivation  of  some  favourite  article  of  food,  such 
as  the  withholding  of  pudding  for  dinner,  the  denial  of  the  enter- 
tainment which  the  child's  companions  are  allowed  to  enjoy,  the 
reproof  of  the  teacher — all  these  may  be  made  use  of  to  impress 
upon  the  child  that  wrongdoing  is  unpleasant,  and  that  it  is 
wisdom  to  be  good. 

It  is  very  important  that  the  whole  demeanour  of  the  teacher 
should  be  kind  and  sympathetic,  gentle  but  firm,  and  that  all 
petting  and  spoiling  should  be  rigorously  avoided.  Approbation, 
if  earned,  should  be  bestowed  ungrudgingly,  and  will  be  found  a 
powerful  incentive  to  further  progress  and  factor  in  moral  train- 
ing. Disapprobation,  if  consistently  expressed,  is  often  equally 
efficacious  as  a  deterrent. 

With  regard  to  the  infliction  of  corporal  punishment  opinions 
are  somewhat  divergent.  My  own  feeling  is  that  it  should  be 
avoided  wherever  possible.  But  in  cases  of  wilful  and  flagrant 
breackes  of  discipUne  or  open  defiance  of  authority  it  is  not  only 
justifiable,  but  beneficial  ;  in  fact,  it  is  often  the  only  means  by 
which  the  child  may  be  taught  that  respect  for  others  which  is 
the  essence  of  moraUty. 

In  the  task  of  implanting  good  habits  and  the  developing  of 
the  ethical  sense,  the  faculty  of  imitation,  often  so  marked  in 
these  children,  must  never  be  lost  sight  of,  since  it  may  readily 
be  turned  to  good  or  bad  account.  It  is  extraordinary  how  mild 
and  gentle  girls,  brought  up  in  an  atmosphere  of  refinement  and 

23—2 


356  Mental  Deficiency 

care,  will  suddenly,  and  upon  the  slightest  provocation,  give  vent 
to  a  torrent  of  the  most  disgusting  and  obscene  abuse  which  they 
may  have  heard  by  chance  on  some  solitary  occasion.  It  is  of 
the  highest  importance  that  the  surroundings  and  the  tone  of 
mentally  deficient  persons  should  be  well  ordered  from  the  very 
beginning,  and  there  is  no  doubt  that  the  home  environment  of 
early  life  exercises  a  most  potent  influence  in  after-years.  We 
cannot  expect  these  children  to  become  affectionate,  sympathetic, 
and  generous  unless  these  qualities  are  evident  in  the  lives  of 
those  about  them,  and  a  rigorous  censorship  of  the  entire  social 
atmosphere,  even  with  regard  to  pictures  and  entertainments,  is 
an  absolute  necessity.  If  we  are  to  ensure  truthfulness,  honesty, 
and  uprightness,  it  is  essential  that  parents,  teachers,  and 
physician  should  be  truthful,  just,  and  straightforward  in  all 
their  dealings  with  these  children.  Reward  and  punishment  must 
be  deliberate,  and  apportioned  in  such  a  manner  as  not  only  to 
fit  the  crime,  but  to  establish  its  relationship  in  the  mind  of  the 
child.  Otherwise  it  will  result  in  more  harm  than  good,  and  will 
inevitably  lead  to  a  complete  alienation  of  confidence  and  affec- 
tion. By  the  judicious  imposition  of  punishment  or  reward  which 
the  child  recognizes  as  being  related  to  his  fault  or  virtue,  we 
shall  be  in  no  danger  of  losing  his  love  and  affection  or  violating 
his  sense  of  justice.  We  shall  develop,  rather  than  perplex, 
his  reasoning  power,  and  we  shall  cultivate  his  moral  sense  and 
control  just  as  we  developed  his  intellectual  capacity. 


CHAPTER    XX 

CONCLUSION     H 

In  the  preceding  pages  we  have  attempted  to  give  an  account  of 
the  prevalence,  causation,  pathology,  and  clinical  characteristics 
of  amentia,  as  well  as  of  the  abihties  and  disabilities  of  persons 
suffering  from  this  condition,  and  the  manner  in  which  their  social 
relationship  is  thereby  affected.  There  are  a  few  matters  arising 
out  of  this  account  to  which  we  may  refer  in  conclusion. 

With  regard  to  training,  it  might  be  argued — indeed,  it  is 
sometimes  argued — ^that,  since  we  can  never  cure  these  persons 
or  make  them  really  self-dependent,  the  expenditure  of  time 
and  money  upon  their  education  is  unjustifiable.  This  is  a 
fallacy.  I  fully  recognize  that  we  must  avoid  the  danger  of  their 
training  becoming  a  fashionable  fad,  and  being  carried  to  an 
extent  out  of  all  proportion  to  the  results  hkely  to  be  achieved — 
that,  in  fact,  not  only  must  the  ament  be  sheltered  from  the 
neglect  or  adverse  competition  of  society,  but  that  society  and 
the  ratepayer  must  be  protected  against  the  ament.  I  beHeve, 
however,  that  both  these  ends  are  best  attained  by  suitable 
training,  and  that  the  withholding  of  such  is  not  only  injurious 
to  the  individual  ament,  but  constitutes  a  danger  to  the  State  ; 
moreover,  it  is  an  economic  blunder. 

It  has  been  shown  that  a  considerable  number  of  these  persons 
possess  habits  and  propensities  which  render  them  a  decided 
menace  to  society.  These  are  partly  inborn,  but  they  are  also 
to  a  great  extent  the  result  of  neglect,  and  there  can  be  no 
doubt  that  judicious  and  systematic  training  would  do  much  to 
prevent  their  development.  I  do  not  say  that  such  training 
would  entirely  prevent  crime  and  insanity  in  these  persons,  but 

357 


358  Mental  Deficiency 


I   do   think   that   it  would  do  very  much  to   diminish  these 
conditions. 

f  But  education  not  only  results  in  a  lessening  of  evil ;  it  is 
[attended  with  a  positive  good.  Although  self-dependence  may 
/never  be  attained,  it  has  now  been  amply  shown  that,  in  con- 
sequence of  proper  training,  a  considerable  proportion  of  the 
milder  aments  become  capable  of  useful  and  remunerative 
work.  In  the  case  even  of  persons  of  good  social  position,  this 
is  a  decided  advantage  ;  for  employment  adds  greatly  to  their 
happiness,  as  well  as  diminishes  their  possibilities  for  mischief  ; 
whilst  in  the  case  of  persons  whose  circumstances  are  such  that 
they  must  be  supported  by  the  pubhc,  this  is  an  economic 
consideration  of  great  importance. 

Many  imbeciles,  even,  may  be  trained  to  help  in  the  routine 
work  of  the  institution  or  home,  whilst  in  the  idiots  the  power  of 
self-help  and  cleanliness  which  may  by  this  means  be  acquired  is 
not  to  be  despised. 

These  facts  are  now  generally  recognized,  and  there  are  few 
civilized  countries  entirely  lacking  in  laws  and  institutions  for 
the  training  of  the  mentally  deficient.  It  must  be  admitted, 
however,  that  in  many  cases  the  accommodation  provided  falls 
short  of  the  demand,  and  in  this  country  it  is  at  present  woefully 
inadequate. 

But  .training  alone  is  not  sufficient.  No  one,  of  course,  would 
expect  an  idiot  or  imbecile  to  be  capable  of  taking  care  of  himself  ; 
but  a  large  number  of  people  do  think  that  the  merely  feeble- 
minded youth  or  girl — ^the  educated  product  of  the  special  school 
— ought  to  be  able  to  do  so,  and  the  neglect,  accordingly,  to  sub- 
sequently provide  adequate  supervision  or  after-care  often  results 
in  a  complete  undoing  of  aU  the  good  that  has  been  done. 
.  The  fact  is,  that  although  training  will  certainly  do  much 
to  repress  the  growth  of  vicious,  criminal,  and  insane  ten- 
dencies, and  will  render  the  mildest  grades  of  defect  capable  of 
remunerative  employment,  or  even  of  earning  a  living,  this 
can  only  be  so  "  under  favourable  circumstances."  Competition 
with  the  normal  population  is  impossible,  and,  as  a  result  of 
the  Workmen's  Compensation  and  Employers*  Liability  Acts, 
employment  is  becoming  more  and  more  difficult  to  obtain 
for  these  persons.     Not  only  must  work  suited  to  their  capacity 


Conclusion  359 

be  found  for  them,  but  in  the  great  majority  of  cases  the  wages 
so  earned  must  be  laid  out,  and  a  general  supervision  exercised 
over  their  whole  behaviour,  just  as  in  the  case  of  children. 
Provided  this  be  done,  the  time  and  money  spent  on  training 
will  be  well  repaid,  and  will  result  in  the  transformation  of 
useless,  and  even  dangerous,  individuals  into  useful,  happy,  and 
contented  members  of  society.  Failing  this  supervision,  how- 
ever, aments,  whether  trained  or  otherwise,  will  certainly  de- 
generate, and  will  inevitably  swell  the  population  of  our  asylums, 
prisons,  and  workhouses.  In  the  case  of  females,  it  is  tolerably 
certain  that  even  before  this  can  happen  the  blight  will  have 
been  passed  on  to  a  new  generation. 

The  question  arises  as  to  what  form  this  supervision  should 
take.  At  present,  as  we  have  seen,  the  majority  of  feeble- 
minded persons  in  this  country,  who  are  not  at  home,  where 
often  the  supervision  is  far  from  adequate,  are  (excluding 
criminals  and  lunatics)  resident  in  workhouses  or  in  charitable 
institutions  of  various  kinds.  In  each  of  these  cases  there  is  the 
grave  disadvantage  that  detention  cannot  be  enforced,  but  is 
entirely  subject  to  the  will  of  the  patient  ;  the  majority  of 
workhouses  suffer  from  the  additional  disadvantage  that  they 
provide  no  remunerative  or  systematic  employment. 

It  would  be  beyond  the  purpose  of  this  work  to  enter  into  any 
discussion  on  this  matter,  and  undoubtedly  the  nature  of  the 
provision  must  vary  with,  and  be  dependent  upon,  the  habits, 
propensities,  capacity,  and  character  of  the  individual.  Any 
method  of  administration  which  does  not  take  these  into  account, 
and  which  attempts  to  provide  for  mental  defect  in  the  abstract, 
cannot  be  an  economic  success.  Briefly,  we  may  say  that  to  be 
satisfactory  the  provision  for  each  individual  must  be  of  such  ai 
nature  as  to  (i)  adequately  safeguard  the  interests  of  society] 
against  the  special  pecuUarities  of  the  ament  ;  (2)  protect  tha| 
ament  against  the  evil  suggestions  and  pernicious  influence  01  / 
certain  sections  of  society,  and  at  the  same  time  ensure  himi' 
kindly  treatment ;  (3)  utilize  his  Vorking  capacity  to  the  fuUest] 
and  most  remunerative  extent,  so  that  the  cost  of  provision] 
falls  as  lightly  as  possible  upon  an  already  overburdened  rate/ 
payer.  In  general,  these  three  conditions  will  best  be  fulfilled 
by  compulsory  detention  in  suitable  colonies  or  institutions. 


360  Mental  Deficiency 

With  regard  to  the  prevention  of  propagation  by  these  persons, 
two  methods  have  been  proposed — namely,  the  restriction  of 
their  marriage,  and  their  steriUzation  by  operation. 
l^  In  America,  sterilization  or  asexualization  has  been  performed 
upon  some  hundreds  of  patients,  both  male  and  female,  and  it  is 
contended  that  this  method  has  an  additional  advantage  in  that, 
by  its  means,  many  depraved  habits  and  bestial  propensities 
have  been  cured  and  the  general  behaviour  much  improved. 
But  it  can  never  take  the  place  of  segregation,  and  it  is  a 
method  which  is  at  present  decidedly  repugnant  to  English 
feehng.  My  own  opinion  is  that,  given  proper  training,  followed 
by  adequate  supervision,  it  should  rarely  be  necessary.  Where, 
in  the  judgment  of  the  physician,  it  is  definitely  indicated,  and 
likely  to  be  attended  with  advantage  to  the  patient,  I  do  not 
think  the  parents  or  guardians  would  withhold  their  consent  ; 
but  it  is  a  grave  matter  to  advocate  its  legalization  for  any  and 
every  case  of  mental  deficiency. 

The  question  of  marriage  is,  of  course,  one  of  very  great  import- 
ance, not  only  as  applying  to  those  who  are  actually  mentally 
deficient,  but  in  regard  to  those  who,  non-defective  in  themselves, 
are  yet  the  descendants  of  a  neuropathic  or  otherwise  diseased 
stock,  and  likely  to  beget  amentia  or  other  morbid  mental  and 
physical  conditions. 

There  are  some  persons  of  whom  it  may  be  said  with  certainty 
that  they  will  transmit  disordered  or  enfeebled  conditions  of  mind 
or  body  to  their  children  ;  such,  of  course,  should  never  marry. 
Others,  again,  would  probably  only  do  so  if  conjoined  to  a  person 
of  like  tendencies.  In  yet  others  a  slight  existing  taint  might, 
by  suitable  marriage,  be  diminished,  and,  with  further  selection, 
finally  eradicated.  Although  it  generally  happens  that  the  child 
bears  a  greater  resemblance  to  one  particular  parent,  it  is  never- 
theless a  mixture  of  both,  and  this  is  one  of  Nature's  means  for 
bringing  about  modifications  and  variations  in  the  human  race. 
The  result  of  any  union  is  a  step  either  in  an  upward  or  a  down- 
ward direction. 

The  effect  upon  any  community  of  the  continued  propagation 
of  the  unfit  is  simply  a  question  of  mathematics.  As  soon  as 
that  stage  is  reached  at  which  there  is  a  preponderance  of  persons 
suffering  from  diminished  moral,  intellectual,  and  bodily  vigour, 


Conclusion  361 

that  community  is  inevitably  doomed  ;  and  history  shows  that 
this  has  repeatedly  happened  to  the  civilizations  of  the  past, 
although  Mankind  undoubtedly  continues,  and  will  continue,  to 
progress.  Whether  the  account  of  Noah  and  the  Ark  be  con- 
sidered literally  true  or  not,  it  contains  a  world  of  meaning  for 
the  thoughtful  student  of  human  evolution. 

The  importance  of  the  question  of  marriage,  therefore,  and 
particularly  the  marriage  of  the  "  unfit,"  cannot  be  too  strongly 
urged.  It  is  far  too  often  entered  upon  without  any  thought 
beyond  the  convenience  or  taste  of  the  contracting  parties,  and, 
indeed,  not  always  with  even  that  amount  of  considera- 
tion ;  but  sooner  or  later  we  shall  be  compelled  to  consider  its 
effect  upon  future  generations.  Considering  the  amount  of 
attention  which  is  bestowed  upon  the  breeding  of  our  horses, 
cattle,  dogs,  and  even  our-  vegetables,  it  is  surely  not  too  much 
to  ask  that  a  little  thought  should  be  given  to  the  breeding  of 
our  race. 

In  some  of  the  States  of  America  legislation  towards  this  end 
has  actually  been  adopted,  the  marriage  of  epileptic,  imbecile, 
and  feeble-minded  persons  being  prohibited  by  law  ;  but  what 
may  be  the  practical  effect  of  these  regulations  I  have  been 
unable  to  ascertain. 

I  see  no  reason  why  such  restrictions  with  regard  to  persons 
suffering  from  mental  deficiency  should  not  be  made  in  this 
country,  although  at  present  they  are  hardly  hkely  to  be  passed 
with  reference  to  any  less  pronounced  conditions.  But  the 
relation  of  the  sexes  cannot  be  entirely  controlled  in  this  com- 
pulsory way,  and  it  seems  to  me  that  it  is  chiefly  to  the  educa- 
tion of  public  opinion  and  the  gradual  development  of  the  con- 
science of  the  community  that  we  must  look  for  improvement  in 
this  matter  of  the  responsibilities  attaching  to  marriage.  The 
Church  has  peculiar  opportunities  of  rendering  incalculable 
service  to  future  generations  by  pointing  out  the  important 
issues  of  the  marriage  tie  ;  whilst  it  is  at  once  the  solemn  duty 
and  privilege  of  the  Medical  Profession  to  speak  on  this  subject 
in  authoritative  and  unmistakable  terms.  Unfortunately,  the 
tendency  of  recent  legislation  has  often  been  in  a  contrary 
direction.  It  has  aimed  at  quantity  rather  than  quality,  and, 
by  diminishing  in  many  ways  the  responsibilities  of  parents  for 


362  Mental  Deficiency 

their  offspring,  it  has  certainly  not  contributed  to  the  develop- 
ment of  home  life  and  of  that  grit  and  sturdy  independence  of 
character  of  which  we  English  were  formerly  so  proud. 

So  long  as  we  are  content  to  raise  no  voice  against  the  marriage 
of  the  diseased,  the  degenerate,  the  criminal,  and  the  pauper,  and 
are  willing  to  educate,  feed,  clothe,  and  ultimately  pension  as 
many  offspring  as  these  persons  see  fit  to  produce  ;  so  long  as 
legislation  is  permitted  a  free  hand  in  doing  everything  calculated 
to  diminish  parental  and  social  responsibility  and  to  strike  at 
the  very  root  of  any  incentive  to  labour  ;  so  long  as  our  law- 
makers and  would-be  philanthropists  are  blind  to  the  folly  of 
transferring  the  burdens  and  penalties  inevitably  following  care- 
lessness, improvidence,  indifference,  drunkenness,  and  unlimited 
selfishness,  from  the  shoulders  of  those  upon  whom  they  should 
rightly  fall  to  the  careful,  provident,  and  industrious  members  of 
the  State  :  then  so  long  will  these  classes  (and  these  qualities) 
continue  to  be  perpetuated,  and  their  numerical  ascendancy  is 
simply  a  question  of  time. 

Finally,  we  have  to  consider  how  this  disease  may  be  prevented, 
and  this  can  only  be  accomplished  by  dealing  with  its  prime  cause. 
The  origin  of  mental  disease  is  intimately  connected  with  the 
origin  of  disease  in  general,  but,  as  we  have  seen,  there  are  certain 
factors  which  appear  to  have  a  particular  influence  in  initiating 
that  nervous  instability  whose  final  culmination  is  mental  defect. 
To-day  the  chief  of  these  are  chronic  alcohohsm,  tuberculosis, 
mental  worry  and  anxiety,  and  the  hurry  and  scurry,  with  all 
their  attendant  excesses  and  dissipations,  of  modern  life.  Pos-. 
sibly  in  other  ages  other  causes  have  predominated,  but  at  any 
period  they  have  been  excesses  of  some  kind  or  other  which  have 
entailed  an  undue  demand  upon  the  bodily  structure. 

According,  therefore,  as  we  diligently  seek  out  and  conform 
to  the  laws  of  health,  and  as  we  improve  the  manner  of  living, 
the  moral,  mental,  and  physical  fibre,  and  the  general  well-being 
of  our  people,  so  shall  we  be  successful  in  preventing  disease  of 
the  mind. 


APPENDICES 


364 


Mental  Deficiency 


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APPENDIX  II 

METHOD  OF  ESTIMATING  THE  TOTAL  NUMBER 
OF  AMENTS  IN  ENGLAND  AND  WALES 

Although  the  local  investigations  of  the  Royal  Commission  of 
1904  only  relate  to  eleven  areas,  having  an  aggregate  popula- 
tion of  2,321,567,  nevertheless,  provided  certain  corrections 
are  made,  it  is  possible  to  calculate  from  these  returns  the 
total  number  of  aments  in  England  and  Wales  with  tolerable 
accuracy. 

Two  corrections  are  necessary,  for  the  following  reasons  : 
(i)  The  areas  investigated  may  not  be  a  fair  sample  of  the  entire 
country  ;  (2)  the  returns  do  not  include  such  aments  as  are 
certified  under  the  Lunacy  Acts. 

Correction  I. — The  only  means  of  ascertaining  whether  the 
areas  investigated  are  a  fair  sample  of  the  whole  country  is  to 
take  some  similar  condition,  the  total  incidence  of  which  is 
known;  the  only  one  available  being  insanity.  As  remarked 
in  Chapter  II.,  there  are  slight  differences  in  the  relative  inci- 
dence of  amentia  and  insanity  as  a  result  of  environment, 
but,  on  the  whole  the  incidence  of  the  one  is  directly  propor- 
tionate to  that  of  the  other.  Considering  the  close  etiological 
relationship  of  these  two  conditions,  I  think  we  may  assume 
that  the  same  holds  good  throughout  the  country,  or  at  all 
events  sufficiently  so  for  our  present  purpose.  As  we  have  seen 
(see  p.  8),  the  incidence  of  insanity  in  the  eleven  areas  examined 
is  3*15  per  1,000  population,  whereas  the  incidence  of  insanity 
in  England  and  Wales  is  3*42  per  1,000  population.  This  can 
only  be 'due  to  the  fact  that  the  eleven  areas  contain  a  relatively 
greater  proportion  of  districts  in  which  insanity   (and  conse- 

366 


Appendix  II 


367 


the  co-efficient  of   inci- 


quently  amentia)  is  of  low  incidence, 
dence  being 

3:1^= 1-085. 

3-15  ^ 

Correction  II.  Aments  Certified  under  the  Lunacy  Act. — A 
considerable  number  of  idiots  and  imbeciles  are  detained  in 
ordinary  lunatic  asylums,  etc.,  and  their  number  is  very  difficult 
to  calculate,  for  the  reason  that  the  proportion  varies  in  different 
localities.  From  the  Report  of  the  Lunacy  Commissioners, 
which,  however,  does  not  give  the  actual  figures,  idiots  and 
imbeciles  would  appear  to  comprise  about  5  or  6  per  cent,  of  the 
asylum  population.  I  am  convinced,  however,  that  this  estimate 
is  much  too  low.  From  information  kindly  placed  at  my 
disposal  by  the  medical  superintendents  of  the  asylums  of 
Manchester,  Birmingham,  Somersetshire,  Wiltshire,  Carmarthen, 
and  Northumberland,  as  well  as  from  my  own  examination  of 
a  number  of  workhouses  and  the  asylums  of  the  London  County 
Council,  I  have  come  to  the  conclusion  that  if  the  "  notified 
insane  "  of  the  county  and  borough  asylums,  the  Metropolitan 
District  asylums,  the  workhouses,  and  the  outdoor  paupers,  be 
considered  in  the  aggregate,  they  will  contain  about  10  per  cent, 
of  idiots  and  imbeciles,  in  the  proportion  of  one  idiot  to  three 
imbeciles.  The  number  of  the  above  classes  throughout  the 
country  is  112,702  ;*  there  are  consequently  11,270  aments 
certified  under  the  Lunacy  Act. 

But  this  is  not  the  whole  of  the  certified  aments.  As  a  result 
of  personal  inquiries,  I  am  of  opinion  that  at  least  another  5  per 
cent,  of  the  inmates  of  county  and  borough  asylums  are  feeble- 
minded. Many  of  these  owe  their  incarceration  to  epilepsy  or 
insanity,  but  the  real  condition  is  mental  deficiency,  and  I  think 
that  they  should  be  classed  with  the  aments  rather  than  the 
insane.     Their  number  may  be  stated  approximately  as  4,450. 

♦  The  figures  given  in  the  Sixtieth  Annual  Report  of  the  Lunacy  Commis- 
sion  are  as  follows  : 


In  county  and  borough  asylums  .. 
In  workhouses .. . 
In  Metropolitan  District  asylums 
Outdoor  paupers 


89,342 

11,151 

6,591 

5,618 


112,702 


368  Mental  Deficiency 

Consequently  the  total  number  of    aments  in  England  and 
Wales  is  approximately  as  follows  : 


Aments  ascer- 
tained in  areas  Pop.  England  and  Wales, 
investigated.  1901.  Coefficient  of 

8,079       X        32>525.7i6 
2,321,567 

Pop.  of  areas. 


incidence.  Uncertified. 

X        1085       =        122,809 


J    Idiots  and  imbeciles.  Feeble-minded.  Certified.^ 

t        11,270         +         4,450         =         15,720/ 
=     138,529  Total  Aments. 


It  is  necessary  to  point  out  that  in  the  Report  of  the  Royal 
Commission  the  total  number  of  "  mentally  defective  persons  " 
(apart  from  certified  lunatics)  in  England  and  Wales  is  estimated 
at  149,628.  In  making  this  calculation  the  Commissioners 
assume  that  the  statistics  ascertained  regarding  the  districts 
investigated  are  applicable  to  England  and  Wales  generally,  and 
consequently  their  total  estimate  should  be  less,  and  not  more, 
than  that  arrived  at  by  myself.  This  increase  in  the  estimate  of 
the  Royal  Commission  appears  to  be  due  to  the  inclusion  of  sane 
epileptics,  and  since,  in  my  opinion,  these  should  not  be  classed 
as  aments,  and  since  also  I  believe  that  the  results  of  the  local 
investigations  are  not  strictly  applicable  to  the  whole  country,  I 
have  thought  it  advisable  to  make  an  independent  calculation. 
It  will,  of  course,  readily  be  understood  that  no  calculation  of 
this  kind  can  be  other  than  approximate,  and  even  were  a  house 
to  house  visitation  practicable  it  is  doubtful  whether  the  statistics 
would  be  absolutely  accurate. 

With  regard  to  the  total  number  of  aments  in  England  and  Wales 
who  are  urgently  in  need  of  provision  at  the  present  time  (for  reasons 
which  have  been  stated  on  p.  286),  there  are,  inclusive  of  feeble- 
minded ("  mentally-defective ")  children,  according  to  my 
estimate  61,525,  or,  acc9rding  to  the  estimate  of  the  Royal 
Commission,  66,509.  These  numbers,  again,  are  only  approxi- 
mate, but  they  are  sufficiently  near  for  practical  purposes. 

The  areas  in  Scotland  and  Ireland  which  were  investigated  by 
the  Royal  Commission  are  not  sufficiently  numerous  to  enable 
a  corresponding  estimation  to  be  made  regarding  those  countries  ; 


Appendix  II 


369 


it  may  be  stated,  however,  that  in  Glasgow  there  were  ascertained 
to  be  present  1,614  mental  defectives,  equivalent  to  0*26  per 
1,000  population  ;  whilst  in  the  four  areas  examined  in  Ireland 
there  were  1,527  mental  defectives,  equivalent  to  0*57  per  1,000 
population.  But  it  is  impossible  to  conclude  that  these  figures 
are  applicable  to  these  countries  as  a  whole,  and,  therefore,  as  the 
Commissioners  remark,  they  are  merely  given  for  what  they  are 
worth. 


24 


APPENDIX   III 

THE  LAW  OF  ENGLAND  CONCERNING   AMENTIA 

The  law  of  England  regarding  the  care  and  control  of  persons 
suffering  from  amentia  is  at  present  very  far  from  satisfactory. 
It  was,  in  fact,  to  a  great  extent  the  recognition  of  this  which  led 
to  the  appointment  of  the  Royal  Commission  of  1904,  "  to  con- 
sider and  report  upon  the  existing  methods  of  dealing  with  idiots 
and  epileptics,  and  with  imbecile,  feeble-minded,  or  defective 
persons  not  certified  under  the  lunacy  laws." 

The  Commissioners  have  now  furnished  their  Report,  and  their 
conclusions  and  proposals  are  set  forth  in  eighty-nine  recom- 
mendations.* These  are  based  upon  a  voluminous  mass  of 
evidence,  a  series  of  careful  local  investigations  conducted  by 
medical  men,  and  the  personal  visits  of  several  of  the  Com- 
missioners to  institutions  in  America  and  on  the  Continent. 
The  conclusions  ar.e  formulated  with  conspicuous  care  and  ability^ 
and  there  can  be  no  doubt  that  as  a  whole  they  are  extremely 
sound,  and  that  their  adoption  would  do  very  much  indeed  to 
solve  the  pressing  problem  of  the  mentally  deficient  of  this 
country.  It  is  therefore  earnestly  to  be  hoped  that  the  Legisla- 
ture will  not  long  delay  giving  effect  to  them. 

In  view  of  this  report,  the  effect  of  which  would  be  materially 
to  alter  the  present  methods  of  dealing  with  aments,  I  feel  that 
any  lengthy  account  of  the  law  as  it  stands  to-day  is  unnecessary. 
I  shall  therefore  confine  myself  to  a  brief  outline  of  the  existing 
law  and  a  short  sketch  of  the  main  modifications  proposed. 

*       *  Report  of  the  Royal  Commission  on  the  Care  and  Control  of  the 
Feeble-Mind ed,  1908.     Vol.  viii. 

370 


I 


Appendix  III  371 


The  Present  State  of  the  Law. 

Idiots  and  Imbeciles. — "  Idiots  "  come  within  the  provisions  of 
two  statutes — viz.,  the  Lunacy  Act  of  1890  and  the  Idiots  Act 
of  1886.     "  Imbeciles  "  come  within  the  latter  only. 

1.  According  to  the  Lunacy  Act  of  1890  [53  Vict.,  ch.  5], 
"  *  lunatic  '  means  an  idiot  or  person  of  unsound  mind  ;"  hence 
idiots  may  be  certified  and  committed  to  care  in  precisely  the 
same  manner  as  "  lunatics  "  as  ordinarily  understood. 

2.  Under  the  Idiots  Act  of  1886  [49  and  50  Vict.,  ch.  25],  ''  an 
idiot  or  imbecile  from  birth  or  from  an  early  age  may,  if  under 
age,  be  placed  by  his  parents  or  guardians,  or  by  any  person 
undertaking  and  performing  towards  him  the  duties  of  a  parent 
or  guardian,  and  may  lawfully  be  received  into,  and  until  of  full 
age  detained  in,  any  hospital,  institution,  or  licensed  house 
registered  under  this  Act  .  .  .  upon  the  certificate  in  writing  of  a 
duly  qualified  medical  practitioner." 

This  certificate,  which  is  accompanied  by  a  statement  of 
particulars  signed  by  the  parent  or  guardian,  is  in  a  prescribed 
form,  and  is  to  the  effect  that  the  person  "  is  an  idiot  {or  has  been 
imbecile  from  birth,  or  for  .  .  .  years  past,  or  from  an  early  age), 
and  is  capable  of  receiving  benefit  from  [the  institution  (describing 
it)]."  The  person  is,  on  this  certificate,  detained  until  he  is  of 
full  age.  If  he  has  been  so  detained,  he  may,  with  the  consent 
of  the  Commissioners  in  Lunacy,  be  retained  after  he  is  of  full 
age.  If,  on  the  other  hand,  he  be  of  full  age  at  the  time  of 
application,  he  may  be  admitted  on  the  same  certificate  and 
statement. 

All  institutions  for  the  care  of  idiots  have  to  be  registered  by 
the  Commissioners  in  Lunacy,  and  are  inspected  by  them.  They 
are  educational  and  custodial,  and  admission  is  obtained  by 
payment  of  fees  by  relatives  or  pubhc  bodies,  by  election  through 
votes,  or  in  some  cases  by  a  combination  of  both  these  methods. 

Idiots  and  imbeciles  may  also  be  taken  into  the  workhouse,  or 
receive  outdoor  relief  from  the  Poor  Law  guardians  ;  not,  how- 
ever, on  the  ground  of  their  deficiency,  but  on  account  of  being 
paupers,  in  precisely  the  same  manner  as  may  non-defective 
paupers.     But  the  father  of  an  idiot  or  imbecile  child  who  is  in 

24 — 2 


372        '  Mental  Deficiency 


this  way  relieved  by  the  Poor  Law  loses  the  Parliamentary 
franchise. 

Feeble-Minded  Adults. — If  a  feeble-minded  person  cannot  be 
certified  as  ''of  unsound  mind  "  or  "  imbecile  "  under  either  of 
the  preceding  statutes,  he  is  not,  qua  mental  defect,  amenable  to 
any  existing  law.  If  insane,  he  may  be  committed  to  care  in  a 
lunatic  asylum  in  precisely  the  same  way  as  an  ordinary  lunatic. 
If  a  pauper,  he  may  be  granted  indoor  or  outdoor  relief  by  the 
Poor  Law  guardians  on  account  of  his  pauperism.  Or  he  may 
be  found  incapable  of  managing  his  affairs,  and  his  property  safe- 
guarded by  proceedings  in  Chancery.  There  are,  moreover,  a 
number  of  voluntary  homes  and  training  establishments  to  which 
feeble-minded  persons  may  be  sent,  and  some  of  these  homes  are 
certified  by  the  Local  Government  Board  as  institutions  suitable 
for  the  reception  of  applicants  sent  by  the  Boards  of  Guardians. 
But  there  is  no  legal  machinery  by  which  feeble-minded  persons 
may  be  detained  in  these  establishments  against  their  will. 

Feeble-Minded  ("  Mentally-Defective  ")  Children.— Under  the 
Elementary  Education  (Defective  and  Epileptic  Children)  Act  of 
1899  [62  and  63  Vict.,  ch.  32],  the  local  education  authorities  are 
empowered  (but  not  required)  to  make  educational  provision  for 
"  what  children  in  their  district,  not  being  imbecile  and  not  being 
merely  dull  or  backward,  are  defective — that  is  to  say,  what 
children  by  reason  of  mental  or  physical  defect  are  incapable  of 
receiving  proper  benefit  from  the  instruction  in  the  ordinary 
public  elementary  schools,  but  are  not  incapable  by  reason  of  such 
defect  of  receiving  benefit  from  instruction  in  such  special  classes 
or  schools  as  are  in  this  Act  mentioned." 

Where  this  Act  has  been  adopted  and  special  classes  or  schools 
established,  the  attendance  of  feeble-minded  children  can  be 
compelled  between  the  ages  of  seven  and  sixteen  years.  .  After 
that  age  the  education  authority  has  no  further  jurisdiction. 
Where  this  Act  has  not  been  adopted  and  there  are  no  special 
schools,  the  guardians  may,  if  they  see  fit,  place  the  child  in  such 
a  school  in  another  district,  and  maintain  him  there  out  of  the 
rates.  Up  to  September  30,  1906,  the  Act  had  been  adopted  by 
87  local  education  authorities  in  England  and  Wales,  and  on 
August  I,  1907,  special  accommodation  existed  for  a  total  of 
9,082  children,  of  whom  4,946  were  in  London.     The  total  number 


Appendix  III  373 

of  these  feeble-minded  children  in  England  and  Wales,  it  will  be 
remembered,  has  been  estimated  at  50,665,  thus  leaving  41,583 
(or,  according  to  the  estimate  of  the  Royal  Commission,  35,662) 
at  present  unprovided  for. 

Recommendations  of  the  Royal  Commission. 

The  general  tenor  of  the  proposals  of  the  Commissioners  will 
be  evident  from  the  following  summary  of  their  "  Principles 
Adopted  in  Dealing  with  the  Problem  of  the  Mentally  Defective  "  : 

1.  That  persons  who  cannot  take  a  part  in  the  struggle  of  life 
owing  to  mental  defect,  whether  they  are  described  as  lunatics,  or 
persons  of  unsound  mind,  idiots,  imbeciles,  feeble-minded  or 
otherwise,  should  be  afforded  by  the  State  such  special  protection 
as  may  be  suited  to  their  needs. 

2.  That  the  mental  condition  of  these  persons,  and  neither 
their  poverty  nor  their  crime,  is  the  real  ground  of  their  claim 
for  help  from  the  State. 

3.  That,  if  the  mentally  defective  are  to  be  properly  considered 
and  protected  as  such,  it  is  necessary  to  ascertain  who  they  are 
and  where  they  are,  and  to  bring  them  into  relation  with  the 
local  authority. 

4.  That  the  protection  of  the  mentally  defective  person,  what- 
ever form  it  takes,  should  be  continued  as  long  as  is  necessary  for 
his  good.  This  is  desirable,  not  only  in  his  interest,  but  also  in 
the  interest  of  the  community.  It  follows  that  the  State  should 
have  authority  to  segregate  and  to  detain  mentally  defective 
persons  under  proper  conditions  and  limitations,  and  on  their 
behalf  to  compel  the  payment  of  contributions  from  relations 
who  are  able  to  pay  for  their  support ;  or  should  itself  provide 
such  care  and  accommodation  as  may  be  necessary,  either  directly 
or  through  the  local  authority. 

5.  In  order  to  supervise  local  administration  of  this  nature,  a 
central  authority  is  indispensable. 

6.  That  in  regard  to  the  protection  of  property  all  mentally 
defective  persons  should  have  like  privileges. 

7.  It  is  essential  that  there  should  be  the  closest  co-operation 
between  judicial  and  administrative  authorities — in  this  case  the 
Chancery  Division  of  the  High  Court  and  the  Central  Authority. 


374  Mental  Deficiency 

The  manner  in  which  it  is  proposed  to  apply  the  foregoing 
principles  is  briefly  set  forth  in  the  following  extracts  from  the 
Commissioners'  Recommendations  and  Report : 

I.  That  there  be  one  central  authority — to  be  known  as 
"  The  Board  of  Control"  for  the  general  protection  and  super- 
vision of  mentally  defective  persons,  and  for  the  regulation  of  the 
provision  made  for  their  accommodation  and  maintenance,  care, 
treatment,  education,  training,  and  control. 

[Recommendations  I.  and  V.] 

II.  That  there  be  placed  under  the  general  protection  and 
supervision  of  this  central  authority — 

(i)  Persons  of  unsound  mind, 
(z)  Persons  mentally  infirm. 

(3)  Idiots. 

(4)  Imbeciles. 

(5)  Feeble-minded. 

(6)  Moral  imbeciles. 

(7)  Epileptics.  ^        ,_,.  , 
/o     r    I,  •  ^                                      ^^ho  are  also 

8    Inebriates.  V  .   ^     ,  r    .• 

,  ^    T^    _[       77      7        77-7       mentally  detective. 
(9)  Deaf  and  dumb,  or  blind   j  -^ 

[Recommendation  IV.] 

Note. — (i)  corresponds  to  "  lunatics  "  and  "  insane  "  as  ordi- 
narily understood.  (2)  corresponds  to  the  various  forms  of 
"  dementia."  (3),  (4),  (5),  (6),  (7),  (8),  (9),  comprise  the  several 
forms,  varieties,  and  degrees  of  *'  amentia  "  which  have  been 
described  in  this  book,  and  of  which  definitions  have  already 
been  given  (see  Chapter  V.,  "  Classification  "). 

III.  That  the  providing  of  the  necessary  educational  and 
custodial  care  shall  be  in  the  hands  of  the  local  authorities 
(County  Borough,  and  County  Councils  acting  through  a 
statutory  (''  Committee  for  the  Care  of  the  Mentally  Defective  "), 
who  shall  be  under  obligation  to  make  directly  or  indirectly 
suitable  and  sufficient  provision  for  the  manual,  industrial,  and 
other  training  of  all  mentally  defective  children,  as  well  as  for 
the  care  and  control  by  institutions,  homes,  or  houses,  or  in 
observation  or  reception  wards,  or  under  family  guardianship, 


Appendix  III  375 

or  in  any  other  way  of  which  the  Board  of  Control  shall  approve, 
of  all  such  other  sufferers  from  mental  defect  within  their  district 
as  come  within  the  terms  defined  in  Section  II. 

These  local  "  Committees  for  the  Care  of  the  Mentally 
Defective  "  would  therefore  take  over  the  work  of  the  Education 
Committees,  the  Asylum  Visiting  Committees,  and  the  Poor  Law 
Guardians,  in  so  far  as  these  are  concerned  with  the  mentally 
defective. 

[Pars.  532-534  of  Report  and  Recommendations 
XXVIII-XXXIV.,  XLVL,  LXXIV.] 

IV.  With  regard  to  feeble-minded  ("  mentally  defective ") 
children,  the  Commissioners  advocate  a  system  of  record  and 
limited  notification,  but,  believing  that  the  Defective  Children's 
Education  Act  of  1899  by  itself  "  cannot  meet  the  needs  of  the 
mentally  defective,"  they  recommend  that  the  education  and 
training  of  these  should  pass  from  the  Board  of  Education  to  the 
"  Board  of  Control,"  the  local  authority  being  empowered  to 
contract  with  the  educational  authority  for  the  supply  of  schools 
and  classes  or  other  suitable  measures,  but  being  responsible  that 
suitable  control  and  training  is  supplied. 

The  Commissioners  insist  upon  continuity  of  control  as  a 
fundamental  principle,  and  justly  urge  that  the  childhood  and 
schooling  of  mentally  defective  children  cannot  rightly  be 
treated  apart  from  their  after-life,  and  that  no  age  can  be  fixed 
in  their  case  as  separating  school-time  from  supervision  and  after- 
care. 

[Par.  23  of  Report  and  Recommendations 

LXXII.-LXXXVL] 

V.  In  order  to  bring  certain  classes  not  now  certifiable 
(notably  feeble-minded  and  moral  imbeciles)  under  efficient  care 
and  control,  the  Commissioners  recommend  that  the  procedure 
under  the  Idiots  Act  be  extended  so  that  not  only  idiots  and 
imbeciles  whose  parents  or  guardians  desire  to  obtain  for  them 
admission  to  an  idiot  asylum  may  be  admitted  on  a  single  medical 
certificate,  hut  also  that  feeble-minded  persons,  moral  imbeciles, 
and  such  inebriates,  epileptics,  and  blind  or  deaf  and  dumb  persons, 
as  are  mentally  defective,  and  of  any  age,  may  be  admitted  to 
suitable  institutions  in  the  same  way. 


376  Mental  Deficiency 

Further,  that  the  Idiots  Act  and  the  Lunacy  Acts  be  re- 
modelled and  drafted  in  the  form  of  a  single  statute,  which 
should  contain  all  regulations  for  procedure,  certification,  and 
the  supervision  of  institutions,  which  it  may  be  necessary  to  insert 
in  an  Act  for  the  care  and  control  of  the  mentally  defective. 
[Par.  27  of  Report  and  Recommendations 
LXVIII.-LXXI.] 


INDEX 


Abnormal  nerve  signs,  1 1 1 

in  mentally  defective  chil- 
dren, 130 
Abstract  ideas,  107 
Achondroplasia  and  cretinism,  257 
Act,  Defective  and  Epileptic  Chil- 
dren (Education),  124,  372 

Employers'  Liability,  358 

Idiots,  371 

Lunacy,  371 
Action,  deliberate,  112 

impulsive,  1 1 2 

reflex,  112 

spreading,  130 

volitional,  112 
Adenoids  in  Mongolism,  187 
Adenoma  sebaceum,  88 
Esthetic  sense,  293 
After-care,  necessity  for,  358 
Age  at  which  training  should  begin, 

339 
of  aments  at  death,  92 
of     feeble-minded     in     work- 
houses, 282 
of  parents  as  a  cause  of  amen- 
tia, 24 
Agenesis  corticalis,  70 
Agnes  Halonen,  the  case  of,  267 
Alcohol  as  a  cause  of  amentia,  18,  '^7 
effect  of,  upon  eggs,  19 
susceptibility  of  aments  to,  300, 

313 
Alimentary  system,    anomalies   of, 

89 
Allegations,  unfounded,  by  aments, 

134.  316 
Allowance,    Poor  Law,   to   aments, 

284 
Amaurotic  family  idiocy,  249 
Amentia    accompanied    by    poren- 
cephaly or  hemiatrophy,  220, 
221 
acquired,  15,  71 


Amentia,  brain  cells  in,  56 

causation  of,  14 

clinical  varieties  of,  72  et  seq. 

congenital, 1 5,  71 

cretinoid,  182,.  253 

definition  of,  2 

degrees  of,  74  et  seq. 

delayed  primary,  47,  72 

developmental,  47,  72 

diagnosis  of,  324 

due  to  asphyxia  neonatorum, 
213 
birth  injury,  212 
blindness,  265 
cerebral  disease,  196 

lesions,  202 
deafness,  264,  275 
defective    cerebral    nutri- 
tion, 251 
isolation,  263 
malnutrition,  261 
sense  deprivation,  263 
sunstroke,  216 
toxic  lesions,  218 
trauma,  31,  203,  214 
traumatic  epilepsy,  214 

eclampsic,  201 

epileptic,  197 

forms  of,  71 

hydrocephalic,  235 

hypertrophic,  229 

incidence  of,  4  et  seq.     See  also 
Incidence 

inflammatory,  202 

myxcedematous,  253 

pachydermic,  253 

paralytic,  211 

prevention  of,  362 

primary,  ^7,  56,  71,  173.     See 
also  Primary 

prognosis  in,  327 

rachitic,  262 

sclerotic,  224  et  seq. 


377 


378 


Index 


Amentia,  secondary,  47,  64,  71,  194. 
See  also  Secondary 
"  sporadic,"  45 
syphilitic,  240 
toxic,  202 

varieties  of,  71,  173,  194 
vascular,  202 
with  hemiplegia,  212,  214 
moral  deficiency,  293 
motor  aphasia,  218 
paralysis,    166,    192,   204, 

211 
paraplegia,  215 
Aments  and  crime,  298 
and  society,  281 
in  cottages,  288 
in  workhouses,  282,  289 
insane,  310 
location  of,  12,  281 
needing  provision,  286 
number    of.    in    England    and 
Wales,    7,    Z^^\    method    of 
estimating,  366 
pauper,  282 
propagation  by,  288 
receiving  Poor  Law  relief,  282 
sane,  310 
sex  of,  1 3 
Andriezen,  Dr.  L.,  19 
Anomalies,  anatomical,  65,  80,  82, 
129 
of  labour,  27,  29,  46 
physiological,  82,  89,  130 
Aphasia,  motor,  in  amentia,  218 
Appearance   of  mentally  defective 
children,  129 
of  primary  aments,    148,    160, 

166,  171,  194 
of  secondary  aments,  194,  210 
Aristotle  on  temperaments,  109 
Arithmetic  in  idiots  savants,  274 

teaching  of,  351 
Arndt  and  Sklarek,  Gy 
Articulation  in  aments,  117 
Asexualization,  360 
Ashby,  Dr.  H,,  120,  130 
Asphyxia       neonatorum       causing 

amentia,  28,  46,  203,  213 
Association,       capacity       for,       in 
aments,  105 
law  of,  348 
systems,  58,  62 

cultivation  of,  348 
Asylums,  feeble-minded  in,  284,  367 
idiots  and  imbeciles  in,  284,  367 
Atavism  and  microcephaly,  174 
Athetosis,  117,  192 
correction  of,  346 


Athyroidea,  252 
Atrophic  sclerosis,  226 
Attention,  cultivation  of,  347 

in  aments,  103,  161,  167 

in  mentally  defective  children, 
132 

spontaneous,  103 

voluntary,  104 
Audry,  66 
"  Aztecs,"  the,  180 

Baer,  Dr.,  296 
Baillarger,  174 
line  of,  58 
Barr,  Dr.  M.  W.,  272 
Beach,  Dr.  Fletcher,  21,   123,   176, 
229 
and  Shuttleworth,  Drs.,  16,  18, 
20,  23,  27 
Becker,  Helene,  case  of,  180 
"  Bird  man,"  case  of,  180 
Birth  lesions  causing  amentia,  27, 
203,  208,  212,  215 
premature,     causing    amentia, 
30,  46 
Births,  number  of,  to  a  marriage,  39 
Bischoff,  Professor,  180 
Blindness,  congenital, causing  amen- 
tia, 265 

256 

,  38,  62,  198,  263, 


18,  19,  60,  90,  223, 


Blood  in  cretins, 
Bolton,  Dr.  J.  S. 

311 
Bourneville,  Dr. 

226 
Boyd,  Dr.  R.,  51 

Brachycephaly  in  Mongolism,  185 
Brain,  atrophy  of,  70 

in  sclerosis,  225 
bloodvessels  of,  61 
cells  of,  in  amentia,  56 
in  dementia,  64 
imperfect  development  of, 

57 
irregular  arrangement  of, 

56 
numerical  deficiency  of,  56 
Brain  cells,  pigmentation  of,  58 
cortex  of,  58,  61 
development  of  n'ormal,  5 1 
haemorrhage  into,  69 
hemiatrophy  of,  66,  220,  221, 

223 
hypertrophy  of,  60,  229 
in  amentia,  65 
in  cretinism,  255 
in  criminals,  296 
in  dementia,  70 
in  microcephaly,  176 


Index 


379 


Brain,  in  Mongolism,  184 
in  sclerosis,  59,  234 
inflammation  of,  69,  202 
malformations  of,  66 
membranes  of,  70 
morbid  anatomy  of,  65 
regions  of,  affected  in  amentia, 

62 
situation  of  changes  in,  61 
size  of,  and  intelligence,  176 
range  of  normal  variation 
in,  176 
weight  of  normal,  176,  364 
in  hemiatrophy,  220,  223 
in   hypertrophic   amentia, 

229 
in  microcephaly,  176 
in  Mongolism,  184 
in  porencephaly,  220,  223 
Bridgman,  Laura,  case  of,  266 
Broca,  Professor,  52 
Brothers  and  sisters  of  aments,  con- 
dition of,  38 
Brunet,  Dr.  D.,  229 

Caldecott,  Dr.  C,  16,  92,  93,  96,  188, 

259,  ^7Z,  275 
Cappelletti,  Dr.,  323 
Cardiac  lesions  in  Mongolism,  187 
Cardona,  Dr.  F.,  180 
Care,    inadequate,     a^ments nnHftr, 

Caswell,  Oliver,  case  of,  267 
Catarrhal  affections  in  Mongolism, 

188 
Causation,  factors  of,  acting  after 
birth,  31  ;   before  birth, 
25  ;  during  birth,  27 
age  of  parents,  24 
alcoholism,  18,  37 
consanguinity,  22 
convulsions,  32,   196 
diseases    of    nervous    sys- 
tem, 16,  37 
ecbolics,  26 

environmental,  16,  24,  47 
epilepsy,  16,  32,  197 
extrinsic,  16,  24,  47 
gross  cerebral  lesions,  5  5 
heredity,  morbid,  15,  34 
intrinsic,  15,  16,  35 
illegitimacy,  26 
injuries,  27,  31 
in  regard  to  local  varia- 
tions of  incidence,  48 
malnutrition,  33 
maternal  impressions,  26 
plumbism,  22,  25 


Causation,    factors    of,    premature 
birth,  30,  46 
primogeniture,  30 
rickets,  t^i,  262 
slum  life,  48,  127 
sunstroke,  32,  216 
syphilis,  21 
toxic,  31 

tuberculosis,  20,  37 
of  primar}'-  amentia,  n 
of  secondary  amentia,  47 
Cells  of  brain,  development  of,  5  2 
in  amentia,  56 
in  dementia,  64 
Cerebellum,  atrophy  of,  234 
in  hydrocephalus,  235 
in  Mongolism,  184 
lesions  of,  in  amentia,  67 
Cerretti,  the  brothers,  180 
Character  in  the  feeble-minded,  149 
Charitable  institutions,   aments  in, 

12,  288 
Charts  of  family  histories,  41-45 
Children    born    during   insanity   of 
mother,  27 
dull  and  backward,   141 
dull  owing  to  disease,  144 
epileptic,  145 
feeble-minded,  123 
insane,  145 

mentally  defective,  123 
of    delayed     mental    develop- 
ment, 143 
Choking,  liability  of  idiots  to,  167 
Chorea  in  aments,  117,  191 
Choreiform  movements,  212 
Circulation  in  Mongolism,  187 
Civil  incapacity  of  aments,  309 
Classification  of  amentia,  71 

table  of,  77 
Clinical  varieties  of  primary  amen- 
tia, 173 
of  secondary  amentia,  194 
Clothing  of  aments,  334 
Clouston,  Dr.  T.  S.,  86,  87 
Colour-blindness  in  aments,  84 

discrimination,   cultivation  of, 

.342 
Commission,  Lunacy,  8 

of  Legislature  of  Connecticut, 

16 
Prison,  299 

Royal,  on  care  and  control  of 
feeble-minded  (of  1904),  4, 
125,  147,  281,  288,  299,  368, 

373 
Royal,  of  Sardinia  on  cretins, 

253 


38o 


Index 


Commission,  Scottish  Lunacy,  290 
Committee,  Anthropometric,  296 
Departmental,     of     Board    of 
Education,  124 
Common  sense,  lack  of,  in  aments, 

158 
Compensation  of  neurones  in  cere- 
bral lesions,  206 
Complications  of  primary  amentia, 

190 
Consanguinity  as  a  cause  of  amen- 
tia, 22 
Consecutive  lesions  of  brain,  6j 
Consonantal     defects     in     aments, 

121 
Contemporaries  of  aments,  38 
Contractures  in   paralytic   aments, 
211 
in  sclerotic  aments,  226 
Control,  defect  of,  in  aments,  115, 
133,  299 
influencing     responsi- 
bility, 306,  307 
inadequate,  286,  287 
Convulsions  (see  also  Epilepsy)  as  a 
cause  of  amentia,  32,  196,  201 
as  a  cause  of  death,  96 
in  amaurotic  family  idiocy,  250 
in  amentia  due  to  cerebral  dis- 
ease, 211 
in  epileptic  amentia,  199 
in  hydrocephalus,  237 
in  mentally  defective  children, 

138 
in  microcephalics,  179 
in  Mongolism,   189 
in  primary  amentia,  190,  191 
in  sclerotic  amentia,  225,  226, 

230,  233 
in  syphilitic  amentia,  243 
Jacksonian,  211 
predisposition  to,  201 
acquired,  202 
Co-ordination,  defects  of,  115 

development  of,  345 
Coprolalia,  121 
Corporal  punishment,  355 
Corpus  callosum  in  aments,  55,  67 
Cortex  cerebri,  56,  62  ' 

in  sclerosis,  234 
Cottages,  aments  in,  288 
Country,     employment    of    feeble- 
minded in,  283 
Craniectomy  in  amentia,  332 
Cranium,  anomalies  of,  in  aments, 
70,  84 
in  criminals,  296 
artificial  compression  of,  29 


Cranium,  in  hydrocephalus,  235,  237 
and  rickets,  237 

in  hypertrophic  aments,  229 

in  microcephalics,  177 

in  Mongolism,  185 

mensuration  of,  85 

oxycephalic,  177 

premature  synostosis  in  micro- 
cephaly, 174 

"sugar-loaf,"  177 
Cretinism,  251 

endemic,  251 

description  of,  252 
incidence  of,  252 

sporadic,  253 

causation  of,  253 
description  of,  255 
differential    diagnosis    in, 

257 
pathology  of,  254 
prognosis,  331 
treatment   and  its  result, 

^      .      .       ^58 
Cretmoid  idiocy,  182 
Criminal   actions  in  feeble-minded 
persons,  157,  298 
aments,  298 

and  insanity,  300,  314 
number  of,  299 
responsibility  of,  305 
types  of,  299 
responsibility,   305 
Criminals,  habitual,  antecedents  of, 
297 
mental  characteristics  of, 

297 
physical  characteristics  of, 
296 
potential,  295 
relation  of,  to  aments,  295 
Crocker,  Dr.,  89 
Crothers,  Dr.,  18 
Crowley,  Dr.  R,,  128 
Cruelty  of  feeble-minded  children, 

134 
of  idiots,  169 
Cunning  of  aments,  134,  301,  302 
Cunningham     and     Telford-Smith, 

Drs.,  181 
Cure  of  mental  deficiency,  127,  328 
Cutaneous  sensation,  10 1 

system,  anomalies  of,  88 
Cuvier,  brain  of,  176 

Dahl,  Dr.  Ludwig,  17 
Dalton,  Dr.,  181 
Darenth  asylum,  22,  28 
Darwin,  Dr.  G.,  23 


Index 


381 


Deaf  -  mutism     causing    secondary- 
amentia,  264;  cases  of,  264- 
267,  303,  304 
in  primary  amentia,  193 
Deafness,  cause  of,  81,  100 
causing  amentia,  264 
Death,  age  at,  in  amentia,  92 
in  Mongolism,  188 
causes  of,  in  amentia,  94,  96 
Definition  of  amentia,  2 

of  feeble-mindedness,  75 
of  idiocy,  76 
of  imbecility,  76 
of  mentally  defective  child,  75 
of  moral  deficiency,  76 
of  "  normal  "  mind,  2 
Degeneracy,  stigmata  of,  anatomi- 
cal, 80 
in  aments,  78,  194 
in  criminals,  296 
physiological,  89 
Degeneration  of  brain  cells,  64 
Degrees  of  amentia,  description  of, 

74 
prognosis  in,  331 
Delisle,  Dr.,  30 
Delivery,  instrumental,  as  a  cause 

of  amentia,  29 
Delusional  insanity,  316 
Delusions  in  aments,  300,  314 
Dementia,  condition  of  brain  in,  62 
distinguished     from     amentia, 

I,  3 
in  epilepsy,  197,  317 
in  insanitY:,  317,  3 1 9  e/  seq. 
in  primary  amentia,  317 
in  syphilitic  amentia,  242 
Dentition  in  aments,   time  of,   90, 

364 
in  cretins,  255 
Deprivation,  amentia  due  to,  263 
Destructiveness  in  idiots,  169 
Developmental     anomalies     in 
aments,  65,  80,  89,  194 
in  criminals,  296 
data,  normal,  364 
or  delayed  primary  amentia,  47 
Development,  delayed,  128 

in  children,  129,  143 
imperfect,  of  nerve  cells,  57 
of  normal  brain,  5 1 
Diagnosis  of  amentia,  324 
of  cretinism,  257 
of  feeble-mindedness,  158 

in  children,  138 
of  hydrocephalus,  237 
of  hypertrophy  and  hydroceph- 
alus, 229 


Diagnosis  of  idiocy  and  imbecility, 
171 
of  mentally  defective  children, 

of  syphilitic  amentia,  243 
Dietary  in  amentia,  334 
Disposition    in   amentia,    109,    134, 
150,  162,  168 
due  to  cerebral  lesions,  210 
hydrocephalus,  236 
hypertrophy,  230 
in  cretins,  256 
Dobson,  Dr.  M.  B.,  235 
Donaldson,  Dr.  H.  H.,  266 
Down,  Dr.  J.  Langdon,  19,  20,  21, 
23,  24,  47,  86,  87,  91,   181, 
185,  210,  274,  329 
Down,  Dr.    R.  Langdon,    187,  188, 

271,  271 
Drawing,  capacity  for,  in  mentally 
defective  children,  137 
in  idiots  savants,  272 
Drugs  in  amentia,  332 
Dugdale,  Dr.  R.  L.,  298 
Dull  and  backward  children,  141 
Dullness,    mental,    due   to   disease, 

144 
Duncan,  Dr.  Matthews,  24 
Dunces  compared  with  aments,  141 

Ear,  anomalies  of,  in  aments,  80 
in  criminals,  81 
in  insane,  81 
and  hearing,  100 
disease  of,  100 
Earlswood  Asylum,  particulars  re- 
garding    mortality     in, 
92  et  seq. 
the  Genius  of,  275 
Earnings  of  feeble-minded  persons, 

284,  285 
Ecbolics  as  a  cause  of  amentia,  26 
Echolalia,  122 
Eclampsia  and  epilepsy,  202 

as  a  cause  of  amentia,  33,  202 
"  Eclampsic  "  amentia,  201,  218 
Edinger,  Professor,  236 
Educability  of  aments,  339 

of  mentally  defective  children, 
132 
Education  Act  regarding  defective 
and  epileptic  children,  124 
Board   of,   report    of    Depart- 
mental Committee,  124 
of  aments,   general  principles, 

335 
home,  339 
industrial,  351 


382 


Index 


Education  of  aments,  intellectual, 

347 

moral,  353 

objects  of,  335 

religious,  353 

school,  341 

technical,  351 

value  of,  358 
Ego,  perversion  of  the,  310 
Eichler,  Professor,  55 
Ellis,  Dr.  Havelock,  296,  297 
Emotion  in  feeble-minded  persons, 

155 
in  mentally  defective  children, 

133 
in  primary  aments,  no,  168 
in  secondary  aments,  210 
Employment  of  feeble-minded  per- 

151,  155.  358 
in    country    districts, 

283 
in  workhouses,  283 
vagrants,  285 
Encephalitis  causing  amentia,  217 

pathology  of,  68 
Enteric  causing  amentia,  203 
Enumeration  of  aments,  4  et  seq., 

366 
Enuresis,  treatment  of,  334 
Environment  and  heredity,  relative 
importance  of,  34 
and    mentally    defective    chil- 
dren, 127 
factors  of,  causing  amentia,  24, 
47.     See  also  Causation 
Epicanthus,  84 

Epilepsy,     acquired    predisposition 
to,    202.     See    also    Convul- 
sions 
and  eclampsia,  202 
as  a  cause  of  amentia,  16,  32, 

198 
as  a  cause  of  dementia,  197 
exciting  factors  of,  202 
in  children,  145 
in  feeble-minded  persons,  191 
in  gross  cerebral  lesions,  190 
in  idiots,  167,  191 
in  imbeciles,  160,  191 
in  microcephalics,  179 
in  primary  amentia,  117,  190 
Jacksonian,  211 
predisposition  to,  202 
psychic,  62,  354 
relations   of,  to  amentia,    196, 

204 
traumatic,     causing     amentia, 
214 


Epilepsy,  treatment  of,  334 
"  Epileptic  "    amentia,    description 
of,  197 
illustrative  cases  of,  199 
prognosis  in,  331 
Epileptic  insanity,  318 
Erotic  tendencies  in   aments,    180, 

290 
Esquirol,  Dr.,  75,  118 
Ethnic  types  of  amentia,  73 
Examination  of  mentally  defective      ^ 

children,  139 
Excitement    determining    insanity, 

313 
in  aments,  155,  162,  168,  300 
Exhaustion  of  mother  as  a  cause  of 

Mongolism,  183 
Expression    in    mentally    defective 

children,  130 
Extent    of    lesions    in    secondary 

amentia,  207 
Extrinsic  factors  causing  amentia, 

24,  47 
Eye,    anomalies    of,    84.     See    also 
Vision 
drill,  346 
Eyes  in  Mongolism,  187 

"  Facile  "  aments,  290,  299 
Factors  of  causation  in  regard  to 

local  variations  of  incidence,  48 
Fagge,  Dr.  Hilton,  253 
Family  history  charts,  41-45 
Farr  and  Newsholme,  Drs.,  40 
Fatty  tumours  in  cretinism,  256 
Fecundity  of  neuropaths,  39 
Feeble-minded  adults,  147 
character  of,  149 
description  of,  148 
illustrative  cases  of,    151, 

156 
incapacity  of,  154 
in  charitable  institutions, 

12 
in  lunatic  asylums,  12,  284 
in  Poor  Law  institutions, 

12,  282 
number  of,  9,  147 
of    stable    mental    equili- 
brium, 150 
of  unstable  mental  equili- 
brium, 155 
receiving      parish      relief, 

282,  283 
sex  of,  148 
children,  123 

abnormal  nerve  signs  in, 
130 


Inde 


X 


383 


Feeble-minded   children    and   slum 
life,  127 
clinical  varieties  of,  137 
"  cured,"  127 
definition  of,  75,  124 
description  of,  128 
grades  of,  134 
incidence  of,  125,  126 
in  special  schools,  135,  372 
mental  condition  of,  131 
number    in    England    and 

Wales,  125,  373 
physical  condition  of,  129 
scholastic  acquirements 
compared  with  ordinary- 
children,  135 
sex  of,  128 
social  status  of,  128 
stigmata  of  degeneracy  in, 
129 
criminals,  298 
insane,  311 
persons,  147 
vagrants,  285 
Feeble-mindedness,     definition     of, 

75 

Fennell,  Dr.  C.  H.,  186 

Fen  wick.  Dr.  Soltau,  259 

Fere,  Dr.,  19 

Fibres  of  cortex  cerebri,  58,  63 

Fingers  in  Mongolism,  187 

Flechsig,  Professor,  62 

Foetus,  injuries  to,  2^ 

Forceps,  use  of,  as  a  cause  of  amen- 
tia, 29 

Fournier,  Dr.  E.,  21,  241 

Eraser,  Dr.  Alec,  220 

"  Freddy,"  the  case  of,  181 

Fright,  as  a  cause  of  amentia,  26 
determining  insanity,  313 

Freud,  Dr.  S.,  55,  69,  204,  207 

Fundus  oculi  in  amaurotic  family 
idiocy,  250 

Gambetta,  brain  of,  176 
Games,  use  of,  in  training,  346 
Garrod,  Dr.  A.  E.,  187 
General  paralysis  in   aments,    317, 
323 
in  syphilitic  amentia,  242, 

244  et  seq. 
morbid  heredity  in,  241 
Generative    organs,    anomalies    of, 

89,  90 
"  Genetous  "  idiocy,  72> 
Genius,  the,  of  Earlswood  Asylum, 

275 
Germ  plasm,  how  influenced,  35,  36 


Gestation,  importance  of  mother's 

condition  during,  45,  183, -184 
Giacomini,  Professor,  174 
Gill,  Dr.,  289 

Gliosis,  59.     See  also  Sclerosis 
Goitre  in  endemic  cretins,  252 

in  sporadic  cretins,  253 
"  Goose  man,"  the,  180 
Gowers,  Sir  W.  R.,  33,  38,  198 
Gradenigo,  Dr.,  80 
Grandoni,  Antonia,  180 
Gray,  Dr.,  307 
Grenzer,  Dr.,  87 
Grimacing  in  aments,  114 

in  Mongols,  188 
Grinning  in  aments,  114 
Gross  lesions  causing  amentia,  55, 


Habits  and  tricks,  114,  346 
Haemorrhage,  cerebral,  61,  69 
Hair,  growth  of,  in  aments,  88 
in  cretins,  255 
in  microcephalics,  177 
Hallucinations  in  aments,  314     — ' 
Hammarberg,  Dr.,  56 
Hands  in  Mongols,  187 
Hauser,  Kaspar,  the  case  of,  268 
Head-nodding,  114 
Hearing  and  attention,  104 
cultivation  of,  344 
defects  of,  81,  100,  264 
in    amaurotic    family    idiocy, 

250 
in  cretins,  252,  256 
in  hydrocephalus,  236 
in  idiots  savants,  271 
Heart,    anomalies    of,    in    aments, 
89 
in  Mongolism,  187 
Helin,  Dr.  Aug.,  267 
Hemiatrophy  of  brain,  66,  220 
Hemiplegia  and  amentia,  212,  214 
Heredity,  alcoholic,  18 

and  environment,  relative  im- 
portance of,  34   " 
morbid,  arid'consanguinity,  23 
importance  of,  as  a  cause 
'      of  amentia,  xa     "^        ' 
tn'Udtis  operandi  in  causa- 
tion of  amentia,  35 
neuropathic,  16,  17,  20 
in  criminals,  297 
in  general  paralysis,  241 
in  sporadic  cretinism,  253 
in  syphilitic  amentia,  241 
syphilitic,  21 
tuberculous,  20 


384 


Index 


Heubner,  Dr.  O.,  227 
High-grade  amentia,  75 
Hirsch,  Dr.,  244 
Histology  of  primary  amentia,  56 

of  secondary  amentia,  64 
Hjorth,  Dr.  B.,  183 
Holt,  Dr.  E.,  69 
Home  training  of  aments,  339 
Homes,      voluntary,      for      feeble- 
minded, 12,  372 
Horsley,  Sir  Victor,  333 

and  Sturge,  19 
Howe,  Dr.,  18,  266,  274 
Huschke,  Dr.,  184 
Hutchison,  Dr.  R.,  258,  259 
Huth,  A.,  23 

Hybernation  of  aments,  91 
Hydrocephalic  amentia,  description 
of,  235 
and  cretinism,  257 
and  hypertrophy,  229 
illustrative  cases  of,  238 
Hydrocephalus,  acute,  236 
and  hypertrophy,  229 
arrested,  236 
cause  of,  68 
causing  amentia,  235 
cure  in,  236 
in  microcephalics,  235 
in  primary  amentia,  192 
pathology  of,  68 
Hypertrophic  sclerosis,  229 
and  cretinism,  257 
amentia  due  to,  229 
Hypertrophy  of  brain  and  hydro- 
cephalus, 229 
amentia  due  to,  229 
pathology  of,  60 

Ideation  in  aments,   106,    149,  151, 

167 
Idiocy,  absolute,  complete  or  pro- 
found, 171 
amaurotic  family,  249 
and  crime,  298 
apathetic  and  excitable,  168 
by  sense  deprivation,  263 
definition  of,  ^6 
description  of,  166 
diagnosis  of,  171 
differentiation  from  imbecility, 

165 
illustrative  cases  of,  169 
maniacal  excitement  in,  169 
mental  and  nervous  character- 
istics of,  167 
partial  or  incomplete,  166 
physical  characteristics  of,  166 


Idiots,  number  of,  in  England  and 
Wales,  9,  165 
receiving  Poor  Law  relief,  284 
savants,  270  et  seq. 
sex  of,  166 
Illegitimacy  as  a  cause  of  amentia, 

26 
Illegitimate  children  of  aments,  288, 

291 
Ill-health   of  mother   during  preg- 
nancy, 25,  183,  184 
Imagination  in   aments,    106,    161, 
167 
in  mentally  defective  children, 
133 
Imbeciles    and    mentally   defective 
children,  145 
insane,  318 
in  schools,  284 
number    of,    in    England    and 

Wales,  9 
receiving  Poor  Law  relief,  284 
sex  of,  159 
Imbecility,  159 

and  crime,  298 
definition  of,  76 
description  of,  159 
diagnosis  of,  171 
differentiation  from  idiocy,  165 
illustrative  cases  of,  162 
mental  and  nervous  character- 
istics of,  160 
physical  characteristics  of,  160 
Imitation  in  aments,  106,  161,  355 
Imperfect    development    of    nerve 

cells,  57 
Improvement   in    amentia   due    to 
cerebral  lesions,  210 
limitation  of,  339 
Incapacity,  civil,  of  aments,  309 

of  feeble-minded  persons,  154 
Incidence  of  amentia,  4  et  seq. 

in    urban    and    rural    dis- 
tricts, 49,  50,  126 
relative  to  insanity,  1 1,  49  ; 
to  sex,  13 
of  insanity,  1 1 
of  mentally  defective  children 

in  schools,  126 
of    the    respective    degrees    of 
amentia,  9,  50 
Inco-ordination,   115 

correction  of,  346 
Industrial  training,  351 
Infantile  cerebral  degeneration,  249 
Inflammation  of  brain,  69 
Inflammatory    amentia,    202.     See 
also  Vascular 


Index 


38s 


Injuries.     See  Trauma 
Insanity,  alternating,  316 

anatomical  basis  of,  62 

and  amentia,.  3,  310,  311,  314 

and  crime,  300,  314 

and  dementia,  3,  317 

and  town  life,  49 

antecedent,     as     a     cause     of 
amentia,  16 
.delusional,  316 

epileptic,  318 

in  children,  145 

incidence  of,  relative  to  amen- 
tia, II 

in  feeble-minded,  311 

in  idiots  and  imbeciles,  318 

in  mother,  effect  upon  children, 

predisposition    to,    in    aments, 

300,  311 
recurrences  in,  316 
Instability    of    feeble-minded    per- 
sons, 155,  300,  312 
Institutions,    aments    in,     12,    282, 

284 
Instrumental  delivery  as  a  cause  of 

amentia,  29 
Intellectual  sense,  293 
Intelligence  and  size  of  brain,  176 

training  of,  347 
Interest,  arousal  of,  SS7 

importance  of,  in  training,  347 
Ireland,  Dr.  W.  W.,  19,  20,  72,  87, 

229,  236,  253,  290 
Irregular    arrangement     of    .nerve 

cells,  56 
Isolation,    amentia  due   to,    263   et 

seq. 
Itard's  wild  boy,  10 1 

Jacksonian  convulsions,  211 
Jaws,  anomalies  of,  88 
Jendrassik,  60 
Jews  and  amaurotic  family  idiocy, 

249 
"  Joe,"  the  case  of,  181 
Johnson,  Samuel,  29 
Joints  in  Mongolism,  187 
Judgment  in  aments,  107,  149,  161, 

167 
Juke  family,  the,  298 

Kaes,  Professor,  53 

Kalmuc  variety  of  amentia,  181 

Keen,  Dr.,  333 

Keller,  Helen,  case  of,  267 

Kerlin,  Dr.,  18,  20,  23 

Kind,  Dr.,  18 


Kindergarten  occupations  in  train- 
ing, n?.  346 

Kingdon  and  Russell,  Drs.,  249 

Kleptomania,  308 
;    Klob,  Dr.,  55 

I    Knowledge  of  wrong,  and  criminal 
;        responsibility,  306 

Koch,  Dr.  J.  L.  A.,  16 

Kolk,  Schroeder  van  der,  298 

Korosi,  Dr.,  24 

Kundrat,  Professor,  66,  221 

I   Labour,  abnormalities  of,  as  a  cause 

of  amentia,  27,  29,  46 
,    "  Lalling,"  120 

Lamination,    cortical,    in    amentia, 
!  58,  61,  67, 

\  in  sclerosis,  234 

normal,  52 

Lankester,  Dr.,  26 

Lannelongue,  Dr.,  ^t,'^ 

La  Page,  Dr.,  84,  86,  120,  129 

Law  of  England  concerning  aments, 
370 

Lead-poisoning     causing     amentia, 
22,  25 

Legal  responsibility  of  aments,  305 
'   Lesions,  cerebral,  and  amentia,  202- 

207 
1  age  at  occurrence,  205 

initial    sjonptoms    of, 
j  208,  209 

I  nature  of,  207 

j  paralysis  in,  208,  209 

I  prognosis  in,  209,  330 

:  situation    and    extent 

I  of,  207 

consecutive,  of  encephalon,  67 
j  of  motor  cortex,  effect  of,  207 

Lewis,  Dr.  Bevan,  57,  61 

Lips,  anomalies  of,  84 

Little,  Dr.,  29 

Location  of  aments,  12,  281,  286 
needing  provision,  287 

Lock  wards,  aments  in,  289 

Logical  sense  in  aments,  293 

Lombroso,  Professor,  179,  180,  296 

Looft,  Dr.  Karl,  18 
\   Low-grade  amentia,  76 
:   Lucon,  Dr.,  19 

I   Lunatics,  potential,   157,     See  also 
I        Insanity 

■   Malar  flush  in  Mongolism,  187 

;   Malnutrition  as  a  cause  of  amentia, 

i        33,  261 

Mania  in  aments,  314,  318  et  seq. 

Marie,  Dr.,  60 

25 


386 


Index 


Marriage  of  aments,  288,  360 

restriction  of,  360 
Marro,  Dr.,  298 
Masturbation  in  aments,  162 
Maternal  impressions,  26 
Maternity  wards,  aments  in,  289 
Maudsley,  Dr.  H.,  274,  297 
McDowall,  Dr.  T.  W.,  177 
Measles  as  a  cause  of  amentia,  203 
Meat  diet,  334 
Medium-grade  amentia,  76 
Melancholia  in  aments,  314 
Melland,  Dr.,  283,  289 
Membranes  of  brain,  condition  of,  70 
Memory,  cultivation  of,  348 
in  aments,  105,   161,  167 
in  idiots  savants,  272 
in  mentally  defective  children, 
132 
Meningitis  causing  amentia,  219 
Meningo-encephalitis  causing  amen- 
tia, 218 
pathology  of,  68 
Menstruation  in  aments,  90 
Mental  characteristics  of  aments,  98, 
103 
deficiency,  literal  meaning  of,  i 
development,  arrested,  262,  268 
delayed,  262 
normal,  51,  251,  335 
instability      in      the      feeble- 
minded, 155,  300 
stability  in  the  feeble-minded, 
150 
Mentally    defective    children,     123. 

See  also  Feeble-minded  children 
Mcrcier,  Dr.  C,  307,  309,  310 
Meystre,  case  of,  267 
Microcephalic  amentia,   173 
and  atavism,  174 
and  cranial  synostosis,  174 
brain  in,   176 
causation  of,  174 
definition  of,  173 
description  of,  177 
intelligence  in,  178 
morbid  heredity  in,  175 
pathology  of,  175 
prognosis  in,  329 
Microgyria,  66 
Microkinesis,  1 1 1 
Mill.  J.  Stuart,  354 
Mimicry  in  microcephalics,  179 

in  Mongols,  189 
Mind,  disease  of,  3 

normal,  definition  of,  2 

development   of,    51,    251, 
335 


'   Mind,  normal,  range  of,  i 

j,  types  of,  293 

I  relation  of,  to  nerve  cells,  54, 

62 
;    Mind,  Gottfried,  case  of,  272 

Mingazzini,  Professor,  181 
i    Modesty  in  aments,  290 
i    Mongolian  amentia,  181 

amelioration      of      bodily 

signs  in,  188 
and  cretinism,  189 
and  syphilis,  22,  182 
causation  of,  182 
description  of,  185 
mental  and  nervous  char- 

acterstics  of,  188 
pathology  of,  184 
physical  characteristics  of, 

185 
prevalence  of,   182 
prognosis  in,  329 
semi-,  182 
Moon,  Dr.  R.  O.,  202 
Moral  deficiency,  293 

and  amentia,  295 
latent,  295 

and  criminals,  295 
imbecility,  76,  354 
'  sense,  no,  133,  168,  293 

training,  353 
Morel,  Dr.,  19 

Mortality  after  craniectomy,  333 
I   Mortality  of  aments,  91-97 
i  of  cretins,  257 

I   Motor  aphasia  with  amentia,  218 
i  cortex,  lesions  of,  207 

functions  in  aments,  1 1 1 
cultivation  of,  338 
in  idiots  savants,  270 
I   Mott,  Dr.  F.  W.,  21,  221,  241 
Movements,  automatic,  114,  169 
co-ordinated,   1 1 1 
deficient,  113 
deliberate,  112,  115 
development  of,  345 
excessive,  113 
imitation,  116,  346 
impulsive,   112,   115 
inco-ordinated,   1 1 5 
instinctive,   112 
irregular,  114 

correction  of,  346 
reflex,  112 
training  of,  345 
transfer,  116,  346 
spontaneous,  1 1 1 
volitional,  112,  115 
Miiller,  Professor  Max,  121 


Index 


387 


p     Mumbray,  Miss  N.,  135,  344 
^      Murray,  Dr.  G.  R.,  258 
Muscle  sense,  10 1 

•    cultivation  of,  343 
Muscles,  anomalies  of,  88 

atrophy  of,  in  amaurotic  family 

idiocy,  250 
condition    of,    in    "  paralytic  " 

aments,  21 1 
sensations  from,  343 
weakness  of,  in  cretins,  256  ! 

in  sclerosis,  226,  230  | 

Music,      fondness     for,      in     idiots   | 
savants,  274  { 

in  Mongols,  189  t 

value  of,  in  training,  344,  350  • 
Mutilations,  transmission  of,  35 
Myxoedema  and  cretinism,  254 

Napoleon,  brain  of,  176 
National  Vigilance  Society,  290 
Nerve  cells,  development  of  normal, 
52 

in  amentia,  56,  61,  63 

in  dementia,  63,  64 

in  sclerosis,  61 
Nerve  fibres  in  amentia,  58,  63 

tin  dementia,  63 
normal,  53-  63 
signs,  abnormal,  iii,  130,  324 
Nervous  characteristics  of  amentia, 

98 
Neurasthenia  in  children,  145 
Neuroblasts  in  amentia,  57,  64 

in  normal  brain,  52,  62 
Neuroglia,  condition  of,  59,  224 

contraction  of,  225 
Neuropathic   heredity.     See    Here- 
dity 
Newsholme  and  Farr,  Drs.,  40 
Nicholson,  Dr.,  297 
Nobiling- Jolly,  55 
Norman,  Dr.  Conolly,  220 
Nose,  anomalies  of,  84 
in  Mongolism,  186 
Number  of  aments  in  England  and 
Wales,  9,  368 
inadequately       cared 

for,  287,  368 
method  of  estimating. 

Numerical  deficiency  of  nerve  cells, 

j  Nystagmus,  117 

Object-lessons,  value  of,  in  training, 

348 
Occupation  of  aments,  151,  283,  285    i 


Occupations   suitable    for    aments, 

352 
Offences  committed  by  aments,  300, 

301 
Operative    treatment    of    amentia, 

333 
Optic  atrophy  in  amaurotic  family 
idiocy,  250 
in  hydrocephalus,  236 
Organic  sensations  in  aments,  102 
Osseous  system,  anomalies  of,  84 
Otitis  as  a  cause  of  amentia,  203 
Otorrhoea  in  aments,  100 
Outdoor  relief,  aments  in  receipt  of, 

282-284,  286 
Oxycephalic  skull,  177 

Pachydermic  idiocy,  253 
Pain,  appreciation  of,  102,  169 
Palate,  anomalies  of,  86,  87 
causation  of,  87 
cleft,  87 

saddle-shaped,  87 
V-shaped,  87 
Palpebral  fissures  in  Mongols,  185 
Paralysis,     general.     See     General 
paralysis 
in  amentia,  166,  179,  192,  204, 

211,  237 
nature     of,     in     "  paralytic " 
aments,  211 
"  Paralytic  "  aments,  211 
Paraplegia  in  aments,  215 
Parasyphilitic  conditions,  241 
Parents'  disparity  in  age  as  a  cause 

of  amentia,  24 
Parry,  Dr.,  289 
Parturition,  anomalies  of,  27 
Pathology  of  amentia,  $4.  et  seq. 
Paul,  Dr.  C,  22 
Pauper  aments,  281  et  seq. 
Peacock,  Dr.,  52 
Pearce,  Dr.  F.  H.,  92,  96 
Pearse,  Dr.,  289 
Peruvians,  ancient,  176 
Petersen,  Dr.,  86,  271 
Phthisis.     See  Tuberculosis 
Physical  characteristics  of  amentia, 

78  et  seq. 
Physiological  anomalies  of  amentia, 

89  et  seq. 
Pigmentation  of  nerve  cells,  58,  64 
Pituitary  gland,  administration  of, 

in  Mongolism,  190 
Play,  use  of,  in  training,  337,  346 
Plumbism.     See  Lead 
Pneumonia  "  aspiration,"  334 
as  a  cause  of  death.  96 
25—2 


388 


Index 


Polio-encephalitis  of  Strumpell  as  a 

cause  of  amentia,  203 
Poor-Law   institutions,    aments   in, 

12,  282,  284 
Porencephaly,  66 

as  a  cause  of  amentia,  5  5 

double,  222 

in  primary  amentia,  192 

in  secondary  amentia,  220 

pseudo-,  dj,  221 

symptoms  of,  220 
Potential  criminals,  295 

lunatics,  157 
Potentiality    of    cerebral    develop- 
ment, 205 
Potts,  Dr.  W.  A.,  283,  289 
Powell,  Dr.  E.,  128 
Pregnancy,   abnormal  condition   of 

mother  during,  25,  45 
Premature    birth    as    a    cause    of 
amentia,  30,  46 

sjmostosis    in    microcephalics, 

174 
Pressure,  sense  of,  102 
Primary  amentia,  causation  of,  ^^j 
clinical    varieties    of,     'J2)> 

173 
complications  of,  190 
pathology  of,  56 
Primogeniture,  30 
Pringle,  Dr.,  89 

Prisons,  aments  in,  12,  299,  300 
Progeny  of  aments,  289,  290 
of  insane  mothers,  27 
of  neuropaths,  39 
Prognosis  in  amentia,  327-331 

due    to    cerebral    lesions, 
209 
cretinism,  258 
epilepsy,   199 
sense  deprivation,  331 
sclerosis,  225 
syphilis,  245 
Pronunciation,  defects  of,  102 
Propagation  by  aments,  288    . 

prevention  of,  360 
Prostitutes,  289,  290,  292,  299 
Provision,    number    of    aments    in 
need    of,    in     England     and 
Wales,  287,  368 
nature  of,  required,  359 
Puberty,   mental     changes    accom- 
panying, 149,  169 
retardation  of,  in  aments,  90 
in  cretins,  252,  256 
in  syphilitic  aments,  242 
Punishment,    effect    upon    aments, 
109.  301.  355 


Pupils  in  special  schools,  135,  ^^2 

in  syphilitic  amentia,  242 
Purkinje's  cells,  234 

Quatrefages,  19 

"  Rabbit  man,"  the,  180 

Rage,    attacks   of,    in   hypertrophic 
aments,  230 

"  Raphael,  Der  Katzen-,"  272 

Rational  type  of  mind,  293 

Reading,  teaching  of,  350 

Reasoning  in  aments,  107,  149,  161, 
167 
cultivation  of,  348 

Recommendations   of  Royal  Com- 
mission   on    the    Feeble-minded, 

373 
Recurrences  in  insanity,  316 
Reflexes  in  paralytic  aments,  2 1 1 
Regions  of  brain  affected  in  amentia, 

62 
Registrar-General,  39,  40,  97 
Relations   of  amentia  to  insanity, 

311 

of  epilepsy  to  amentia,  196 
Religious  education,  353 

sense,  293 

in  aments,  no,  134 
Rennert,  Dr.,  25 
Respiratory  system,   anomalies    of, 

89 
Responsibility,  conditions  of,  309 

of  aments,  305 
Rewards,  use  of,  in  training,  355 
Rhinitis  in  amentia,  203 
Ribot,  Dr.,  348 
Rickets  and  cretinism,  257 

and  hydrocephalus,  237 

as  a  cause  of  amentia,  -n,  262 
Ross,  Dr.,  222 
Rossi,  Dr.,  297 
i    Rumination,  167 
Russell  and  Kingdon,  Drs.,  249 

Sabatier,  19 
j    Sachs,  Dr.,  69,  70,  249 

Sailer,  Dr.  J.,  60,  234 
I    Sander,  Dr.,  176 
i    Sangford,  266 

Saulle,  Legrand  du,  27 

Savage,  Dr.  G.  H.,  198,  310 

Scalp  in  hydrocephalics,  237 
in  microcephalics,  177 

Scarlet  fever  as  a  cause  of  amentia, 
I        203 

Scholastic  acquirements  of  imbeciles, 
I        161 


Index 


389 


Scholastic  acquirements  of  mentally 

defective  children,  134 
Schools,  imbeciles  in,  284 

special,  description  of  children 

attending,   135 
training,  341 
"  Scissor-legs,"  166 
Sclerosis,  contraction  in,  225,  234 
diffuse,  59 

haemorrhage  in,  61,  234 
hypertrophic,  nodular,  or  tube- 
rous, 60 
in  amentia,  193,  224 
localized,  59 
origin  of,  60 
pathology  of,  59 
Sclerotic  amentia,  224 
diffuse,  225 

atrophic  form,  226 
hypertrophic       form, 
229 
localized,      tuberous,      or 

nodular,  233 
prognosis  in,  331 
Secondary  amentia,  causation  of,  47 
clinical  varieties  of,  7-^,  194 
pathology  of,  64 
prognosis  in,  330 
Seguin,  Dr.  Edouard,  271,  274,  327, 

Sensations,  importance  of,  to  men- 
tal development,  98,  263 
Sense  deprivation,  amentia  due  to, 

263 
Senses,  four  chief,  in  normal  mind, 

293 
Sensory    functions,     abnormal    de- 
velopment,     in      idiots 
savants,  271 
cultivation  of,  338,  342 
in   aments,   98,    131,     160, 

167 
in  cretins,  256 
in  mentally  defective  chil- 
dren, 131 
Sentiment  in  aments,  1 10 
Sex  of  aments,  13 

of  idiots  savants,  270 
of  mentally  defective  children, 
128 
Sexual    instincts,     102,     167,     290, 

298 
Shuttleworth,  Dr.  G.,  21,  91,    123, 
181,  189,  330,  350 
and  Beach,  Drs.,  16,  18,  20,  23, 
27 
Siege  of  Paris,  27 
Sichard.  Dr..  298 


I   Simple  variety  of  amentia,  Jlt  ^73 
•   Situation  of  aments,   12,   281,   286, 
287 
of   brain    changes   in    primary 
:  amentia,  61 

'  of  lesions  in  secondary  amentia, 

!  207 

Skeleton,  anomalies  of,  88 
Skin,  anomalies  of,  in  aments,  88 
in  cretins,  252,  256 
in  Mongols,  187 
Skull  in  amentia,  70,  84.     See  also 

Cranium 
Sleep  in  aments,  1 1 3 
Slums,    effect    of,    in    causation    of 

amentia,  48,  127 
Small-pox  as  a  cause  of  amentia, 

203 
Smell  in  aments,  loi,  271 
cultivation  of,  344 
;    Smith,  Dr.  F.  J.,  248 
j   Society  and  the  ament,  281 
Sollier,  Dr.,  75,  90 
Speech,  consonantal  defects,  121 
cultivation  of,  349 
in  aments,  117 
in  cretins,  255 
in  idiots,  168 
in  idiots  savants,  272 
in  mentally  defective  children, 

131 
in  savages,  120 
in  syphilitic  amentia,  242 
nervous  mechanism  of,  117 
retardation  of,  90 
Spiegelberg,  Dr.,  30 
Spiller,  Dr.  W.  G.,  206 
Spinal  cord  in  amentia,  67 

in  microcephaly,  175 
secondary  sclerosis  of,  234 
Spontaneity,  iii,  335 
deficient,  113 
development  of,  ^^7 
excessive,  114 
Stammerers,  349 
Stature  of  aments,  88,  194 
of  cretins,  255 
of  criminals,  296 
of  mentally  defective  children, 

130 
of  microcephalics,  178 
Stephen,  Sir  Fitzjames,  306,  309 
Sterility  in  cretins,  256 

in  idiots,  167 
Sterilization  of  aments,  360 
Stigmata   of  degeneracy   in   crimi 
nals,  296 
in  insane,  312 


390 


Index 


stigmata  of  degeneracy  in  mentally 
defective  children,  129 
in  primary  aments,  78,  80, 

82 
in  secondary  aments,  194 
Still-births  in  neuropaths,  39 
Striimpell,  Professor,  60 
Stupor  in  aments,  3 1 5 
Stutterers,  349 
Sugar-loaf  cranium,  177 
Suicide  in  aments,  no,  314,  315 
Sunstroke  as  a  cause  of  amentia  32, 

203,  216 
Suspicion  in  aments,  210,  300 
Sutherland,  Dr.  G.  A.,  22,  182,  185. 

187,  258 
Sutures,    cranial,   in   microcephaly, 

174 
Synostosis,    premature,    in    micro- 
cephaly, 174 
Syphilis  as  a  cause  of  amentia,  21, 
241,  243 
Mongolism,  22,  182 
Syphilitic  amentia,  240 

and  general  paralysis,  242 
description  of,  242  | 

diagnosis  of,  243  j 

treatment  in,  244,  332 
toxaemia,  241 

Talbot,  Dr.  E.,  81,  87,  89 
Talents,  special,  in  aments,  270 
Talipes  in  paralytic  aments,  2 1 1 
Taste,  cultivation  of,  344 

defects  of,  loi 
Tay,  Mr.  War  en,  249 
Taylor,  Dr.  F.  R.  P.,  226,  228 
Teeth,  anomalies  of,  88 
Telford-Smith,  Dr.,  187 
Temperament  of  aments,  108 
Temperature,  appreciation  of,  102 
effect  of,  upon  aments,  91 
in    amentia    due    to    cerebral 

disease,  209 
in  cretins,  256 
Thirst  in  aments,  102,  167 
Thompson,  Dr.  J.  Bruce,  296 
Thomson,   Dr.   John,  87,    115,    186, 

254,  255,  258 
Thymus  gland,  effect  of,  in  Mongol- 
ism, 190 
Thyroid   gland,    administration   of, 
in  cretinism,  258 
in  Mongolism,  190 
condition  of,  in  cretinism, 
252,  253 
secretion,  effect  of,  upon  brain, 
254 


Thyroid  secretion,  temporary  arrest 

of,  260 
Tongue,  anomalies  of,  84 
in  cretins,  252,  255 
in  Mongolism,  186 
sucking,  186 
Touch,  sense  of,  10 1 

cultivation  of,  343 
in  idiots  savants,  271 
in  paraplegia,  216 
painful,  344 
Toxaemia,  syphilitic,  241 
Toxic  amentia,  202 

conditions  causing  amentia,  32 
Tracey,  Mr.  Justice,  305 
Tracheotomy,     necessity     for,     in 

aments,  167 
Training,  age  at  which  to  begin,  339 
effect   of,    in    amentia   due   to 
lesions,  206 
sense        depriva- 
tion, 263 
general  principles  of,  335 
home,  339 
industrial,  351 
intelligence,  347 
moral,  353 
of  movement,  344 
of  senses,  342 
of  speech,  349 
school,  341 
value  of,  358 
Train-wrecking    by     aments,     303, 

304 

Trauma  as  a  cause  of  amentia,  27, 
31,  203,  214 

Treatment,  332 

in  cretinism,  258 
in  epileptic  amentia,  201 
in  syphilitic  amentia,  244 
medical,  332,  334 
surgical,  t,^^.  334 

Trelat,  Dr.,  274 

Tremor  in  amentia,  192,  211 

in  sclerosis,  225,  226,  228,  230 
in  syphilitic  amentia,  242 

Tricks  and  habits,  114 

correction  of,  346 

Tuberculosis,  antecedent,  as  a  cause 
of  amentia,  20,  ■^y 
as  a  cause  of  death,  96 

Tuke,  Sir  J.  Batty,  2 

Tuke,  Dr.  Hack,  123 

Turgenieff,  brain  of,  176 

Ultimate  result  of  cerebral  lesions, 

203 
Umbilical  hernia  in  cretins,  256 


Index 


391 


Umbilication   of  sclerotic   nodules, 

225,  234 
Unstable  type  of  feeble-minded,  155 
Urinary  organs,  anomalies  of,  89 
Uterine  exhaustion   as   a  cause  of 

Mongolism,  183 

Vagrancy,  285 

Vanity  in  imbeciles,  162,  278 
Vaquez,  Dr.,  256 
Varieties,  ethnic,  y"}, 

of  mental  action,  109 

of  mentally  defective  children, 

137 
of  mind,  294 

of  primary  amentia,  ji,  173 
of  secondary  amentia,  j-}),  194 
Vascular,    toxic,    or    inflammatory 
amentia,  202 
causes  of,  203 
illustrative    cases    of, 

212  6/  seq. 
initial   symptoms    of, 

208,  209 
mental   condition    in, 

210 
physical  condition  in, 

208 
prospects  of  improve- 
ment in,  210 
Vessels  of  brain,  61,  65,  203 
Vision,  cultivation  of,  342 

defects    of,     and    cortical    de- 
velopment, 263 
in  amaurotic  family  idiocy,  250 
in  amentia,  100 
in  hydrocephalus,  236 
in  idiots  savants,  271 
in  Mongolism,  187 
in  syphilitic  amentia,  242 


Vitality  of  aments,  91 
Vocabulary  of  normal  child,  118 
Vogt,  Professor  C,  174 
Voisin,  Dr.  Felix,  176 

Dr.  Jules,  18,  23,  90,  271 

Walking,  age  at,  in  aments,  90.  255 
Warner,  Dr.  Francis,  iii,  116,  123, 

140,  344,  346 
Watson,  Dr.  G.,  243 
Weight  of  brain  in  aments,  176,  184, 
220,  223,  229 
of  criminals,  296 
of  mentally  defective  chil- 
dren, 130 
normal,  176,  364 
Weismann,  Professor,  35 
Wey,  Dr.  H.,  296 
Whooping-cough     as     a    cause     of 

amentia,  203 
Wilbur,  Dr.,  179 

Will  in  aments,  no,  161,  168,  306 
Wilmarth,  Dr.,  59,  184 
Wilson,  Dr.  G.,  296 
Winslow,  Dr.  Forbes,  273 
Witnesses,  aments  as,  309 
Wizel,  Dr.,  274 
Work,  capacity  of  aments  for,  136, 

149,  151,  156,  161,  189,  283 
Workhouses,  feeble-minded  in,  282 
idiots    and    imbeciles    in,    284, 

288 
maternity    wards,    aments    in, 
289 
Works  of  the  Genius  of  Earlswood 

Asylum,  276 
Writing,  teaching  of,  350 
Wyllie,  Dr.,  120 

Ziegler,  Professor,  55,  66 


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